Upon Completion of This Chapter, You Will Be Able To

King saud university physical assessment Imad lecures 7

SKIN

Objectives

Upon completion of this chapter, you will be able to:

Identify the anatomy and physiology of the skin, hair, and nails.

Develop questions to be used when completing the focused interview.

Explain client preparation for assessment of the skin, hair, and nails.

Differentiate normal from abnormal findings in physical assessment.

Discuss the focus areas related to overall health of the skin as presented in Healthy People 2010 initiatives.

Apply critical thinking in selected simulations related to physical assessment of the skin, hair, and nails.

Overview

The integumentary system includes the skin and accessory structures, the hair, and the nails.

The skin is the largest organ of the body.

The skin protects the body and serves in temperature regulation, synthesis of vitamin D, storage of fat and blood, exertion, and sensation.

Anatomy and physiology review

The skin is composed of the epidermal and dermal layers.

The epidermis is the outermost layer of the skin.

New skin cells are formed in the basal layer and consist of a fibrous protein called keratin.

Melanocytes produce the skin pigment melanin.

The dermis is a layer of connective tissue embedded with hair follicles, sweat glands, oil glands, and sensory receptors.

The subcutaneous tissue stores approximately half of the body’s fat cells.

Sweat glands are the eccrine glands that produce clear perspiration, and the apocrine glands found in axillary and anogenital regions.

Sebaceous glands produce sebum that is usually released in hair follicles.

Hair is a thin fiber compound of dead keratinized cells.

Hair distribution varies in different parts of the body. Vellus hair is pale and of short strands. Terminal hair is darker and is found in the scalp and eyebrows and in the axillary region, pubic region, and legs of adults and in the face and chest of males.

Nails are thin plates of keratinized epidermal cells that cover the distal ends of fingers and toes.

Special considerations

Newborn skin is covered with vernix caseosa.

Infants have skin that is thin, soft, and free of terminal hair.

Infants may be born with lanugo present.

Milia and “stork bites” are common harmless markings in newborns.

Temperature regulation is inefficient in infants because eccrine glands do not secrete until 3 months of age.

Skin pigmentation increases in pregnancy.

Chloasma and the linea nigra are common in pregnancy.

Skin elasticity decreases with aging.

Sebum production decreases and causes dryness in older adults.

The amount of perspiration decreases with aging.

Older adults have a decrease in melanin production resulting in graying hair and increased sensitivity to sunlight.

Nails tend to become thicker and more brittle with aging.

Stress may exacerbate skin conditions.

Visible skin disorders may contribute to problems with self-esteem and body image.

Culture, socioeconomic status, and environment affect the health of the skin, hair, and nails.

Changes in skin color may be difficult to evaluate in people with dark skin. The nurse can inspect the lips, oral mucosa, sclera, palms of hands, and conjunctiva to detect color changes.

Abnormal findings

Abnormal findings in the skin include primary and secondary lesions, vascular lesions, infections, and malignant lesions.

Primary lesions develop on previously unaltered skin.

Secondary lesions are a result of a change in a primary lesion.

Vascular lesions are associated with changes and vessel integrity.

Purpuric lesions result from deposits of blood in tissues following breaks in vessels.

Common skin lesions include measles, varicella, , psoriasis, and dermatitis.

Malignant lesions include basal cell and squamous cell carcinomas,

Abnormalities of the hair include seborrhea, tinea capitis, and alopecia areata.

Infection of hair follicles can result in folliculitis

Hirsutism is excess body hair in females.

Nail abnormalities include spoon nails, splinter hemorrhage, and onycholysis.

Clubbing of the fingers is a result of decreased oxygenation.

Paronychia is an inflammatory problem in nail folds.

Health promotion and client education

Clients who have diabetes need information and instruction about skin care.

Moles must be monitored for change in size, shapes, color, or texture.

Use of sun block and avoidance of sun exposure are important measures to prevent skin damage and cancer across the age span.

Information about the risks of tattooing and body piercing is important for individuals, adolescents, and parents.

All clients should be informed of the importance of self-examination of the skin.

Case study

Ms.x age 32, reports to the Medi-Center with a chief complaint of pain, swelling, and redness at the nails of two fingers on her left hand. Following is an excerpt of the focused interview.

Interview

Nurse: Good morning. Ms. x, I see from your information sheet that you have a problem with the fingernails of your left hand.

Ms. x: Yes. I think it’s my nails, but I’m not sure.

Nurse: The problem involves two digits of the left hand.

Ms. X Yes, the thumb and index finger are the only two. The other three seem to be okay.

Nurse: Looking at your nails, I see they are highly polished.

Ms. x: Yes, I have them done professionally every 7 to 10 days. They were done 5 days ago.

Nurse: Are these your natural nails?

Ms. x: Yes, I have silk wraps on all my nails to help make them stronger.

Nurse: Does the manicurist push and cut your cuticles?

Ms.x: Yes, she does both. Do you think this is from having the manicure?

Nurse: It could be. I’m not sure. I need more information. When did you first notice the pain and swelling?

Ms. x: It started several days after I had my nails done, and now it seems to be getting worse. What is causing this?

Nurse: Is this the first time the manicurist did your nails?

Ms. x: Oh no, Sally has been doing my nails for 3 years. This is the first time I have had anything like this.

Nurse: How much time are your hands and nails in water?

Ms.x: Not much. I use gloves when I do the dishes.

ANSWER

Expert Response

Several questions are provided to challenge your thinking about this case.
Answer each question and compare your answers to the experts.
1. Based on the information presented by Ms. Thalia, what do you think precipitated her problem? / An infection of the cuticles could be due to an ingrown nail or from contaminated instruments used during a manicure. The client stated that she had been receiving manicures from the same person for the last three years. Several other things, such as prolonged use of nail polish or the use of artificial nails, may encourage growth of fungi or damage the nail plate.
2. What other questions should the nurse ask Ms. Thalia regarding her nails? / It would be important for the nurse to inquire as to when the pain and swelling started around the two nails on her left hand. It would valuable to know what medications she may be currently taking because some medications may cause nail changes.
3. When the nurse is examining the client’s cuticles, the client inquires about the cuticle of the nail and exactly what the purpose of the cuticle is on the finger. What does the nurse tell the client regarding her nails and cuticles? / Nails are thin plates of keratinized epidermal cells that shield the distal ends of the fingers and toes. Nail growth occurs at the nail matrix, as new cells arise from the basal layer of the epidermis. As the nail cells grow out from the matrix, they form a transparent layer, called the body of the nail, which extends over the nail bed. A fold of epidermis skin called a cuticle protects the root and sides of each nail. The major functions of the nails are to protect the tips of the fingers, to aid in picking up small objects, and for grasping and scratching.

Glossary

alopecia areata Patchy hair loss.

apocrine glands Glands in the axillary and anogenital regions that are dormant until the onset of puberty, produce a secretion made up of water, salts, fatty acids, and proteins, which is released into hair follicles.

chloasma A skin condition that developes during pregnancy, hyperpigmented patches on the face,also referred to as melasma, gravidum, or “the mask of pregnancy”.

cuticleA fold of epidermal skin protects the root and sides of each nail.

dandruffDead, scaly flakes of epidermal cells.

dermisA layer of connective tissue that lies just below the epidermis.

diaphoresis(Profuse sweating) occurs during exertion, fever, pain, and emotional stress and in the presence of some metabolic disorders such as hyperthyroidism.

ecchymosisBruising.

eccrine glandsGlands which produce a clear perspiration mostly made up of water and salts, which they release into funnel-shaped pores at the skin surface.

edema A decrease in skin mobility caused by an accumulation of fluid in the intercellular spaces.

epidermis The outer layer of skin on the body.

hairA thin, flexible, elongated fiber composed of dead, keratinized cells that grow out in a columnar fashion.

hypodermisThe subcutaneous tissue ,a loose connective tissue that stores approximately half of the body’s fat cells, cushions the body against trauma, insulates the body from heat loss, and stores fat for energy.

keratinA fibrous protein which gives the epidermis its tough, protective qualities.

lanugoThe fine, downy hair of the newborn.

linea nigraA dark line running from the umbilicus to the pubic area, increased pigmentation of the areolae and nipples, and darkened moles and scars seen in pregnant women.

lunulaA moon-shaped crescent which appears on the nail body over the thickened nail matrix.

melaninSkin pigment produced in the melanocytes in the stratum basale.

milia Harmless skin markings on newborns; areas of tiny white facial papules due to sebum that collects in the openings of hair follicles.

Mongolian spots Gray, blue, or purple spots in the sacral and buttocks areas of newborns which fade during the first year of life.

nailsThin plates of keratinized epidermal cells that shield the distal ends of the fingers and toes.