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nursing, health, assessment, carmela domocmat, integumentary system, skin, hair, nails
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THE SKIN
Maria Carmela L. Domocmat, RN, MSN
STEP 1
Maria Carmela L. Domocmat, RN, MSN
STEP 2
Confirm that the
skin is clean
and free from and free from
body odor.
Maria Carmela L. Domocmat, RN, MSN
STEP 3
Cyanosis Carotenemia
Jaundice
Maria Carmela L. Domocmat, RN, MSN
Inspecting the palms is anopportunity toassess overallassess overallcoloration.
Maria Carmela L. Domocmat, RN, MSN
STEP 4
Inspect the skin for even
pigmentation over the body.pigmentation over the body.
Maria Carmela L. Domocmat, RN, MSN
Freckles Versicolor
Vitiligo
Nevus
Vitiligo
Maria Carmela L. Domocmat, RN, MSN
STEP 5
Determine
the Client’s
skin skin
temperature
Maria Carmela L. Domocmat, RN, MSN
STEP 6
Assess the amount
of moisture
on the skin on the skin
surface and
texture.
Maria Carmela L. Domocmat, RN, MSN
STEP 7
Palpate to assess thickness
STEP 8 STEP 8
Palpating to assess skin elasticity
and mobility.
Maria Carmela L. Domocmat, RN, MSN
Testing for skin tenting
Assessing skin turgor
Tenting
Maria Carmela L. Domocmat, RN, MSN
Edema of the
hand
STEP 9
Palpate
to
detectdetect
edemaPitting Edema
Maria Carmela L. Domocmat, RN, MSN
STEP 10
Inspect the
skin for
superficial
Spider Angioma
Venoussuperficial
arteries and
veinsSpider Vein
VenousStar
Maria Carmela L. Domocmat, RN, MSN
STEP 11
Inspect and palpate the skin for
lesion.Referral
If you notice drainagefrom any lesion, put
on gloves beforeproceeding with the
assessment.
Referral
Suspect physical abuse. Be especially
sensitive if client is fearful and has a history
of previous injuries. Obtain medical assistance
and follow your states’ legal requirements to
notify the police or local protective agency.
Maria Carmela L. Domocmat, RN, MSN
STEP 12
Palpate the skin for sensitivity
Maria Carmela L. Domocmat, RN, MSN
Evaluating Skin Lesions
A – (assymetrical)
B – (borders)
C – (color)C – (color)
D – ( diameter)
E – (elevation)
Maria Carmela L. Domocmat, RN, MSN
PRIMARY LESIONS
MACULE, PATCH
NevusFreckles
Nevus
Petechiae
Vitiligo
Maria Carmela L. Domocmat, RN, MSN
Ecchymosis Mongolianspot
Chloasma
Rubella Purpura
Maria Carmela L. Domocmat, RN, MSN
Papule, Plaque
Lichen Planus
WartsEczema
Maria Carmela L. Domocmat, RN, MSN
Psoriasis
Maria Carmela L. Domocmat, RN, MSN
PatchNodule
Tumor
(café-au-lait spot)
Nodule, tumor
PatchNodule
A combination typical of neurofibromatosisMaria Carmela L. Domocmat, RN, MSN
Vesicle, Bulla
Atopic Dermatitis
Vesicle
Maria Carmela L. Domocmat, RN, MSN
Erythema multiforme
Bulla
Chicken Pox
PemphigusMaria Carmela L. Domocmat, RN, MSN
Wheal
Wheal in a drugeruption in an eruption in an infant
Urticaria
Maria Carmela L. Domocmat, RN, MSN
Pustule
Pustular psoriasis
Furuncle
Impetigo
Furuncle
Maria Carmela L. Domocmat, RN, MSN
Acne
Maria Carmela L. Domocmat, RN, MSN
Cyst
Maria Carmela L. Domocmat, RN, MSN
Secondary Skin Lesions
LichenificationMaria Carmela L. Domocmat, RN, MSN
Atrophy
Aged Skin
Striae
Maria Carmela L. Domocmat, RN, MSN
Ulcer
Ulcer fromUlcer from
Venous
Stasis
Maria Carmela L. Domocmat, RN, MSN
Erosion
Apthous Ulcer
Maria Carmela L. Domocmat, RN, MSN
Fissure
Fissured Tongue Athlete’s Foot
Maria Carmela L. Domocmat, RN, MSN
Crust
Ruptured vesiclesvesiclesof herpes simplex
Maria Carmela L. Domocmat, RN, MSN
Keloid
Keloid ofKeloid ofear piercing
Maria Carmela L. Domocmat, RN, MSN
Cancerous Skin Lesions
Nodule
Ulcer
Tumor
Telengiectasia
Maria Carmela L. Domocmat, RN, MSN
Cancerous Skin Lesions
Nodule
Uler Tumor
Telengiectasia
Maria Carmela L. Domocmat, RN, MSN
Kaposi’sSarcoma
Maria Carmela L. Domocmat, RN, MSN
Malignant
MelanomaSuperficial Spreading
Nodular
Serious Type ofSkin Cancer
Maria Carmela L. Domocmat, RN, MSN
Common Skin Variationsin Older Clients
Cutaneous Tags
Maria Carmela L. Domocmat, RN, MSN
Cutaneous Horn
Cherry Angiomas
Senile Lentigines
Cutaneous Horn
Maria Carmela L. Domocmat, RN, MSN
Hair AssessmentHair Assessment
Maria Carmela L. Domocmat, RN, MSN
Inspect the
scalp and
hair
STEP 1�Confirm that the scalp and hair are clean.�Examine strands of hair that are loose or undone.�Part and divide the hair at 1-inch intervals and
observe.
Maria Carmela L. Domocmat, RN, MSN
STEP 2
�Varies according to the level of melanin production
STEP 3
�Roll a few strands of hair between your thumb and forefinger.
Observe the client’s hair color
Assess the textureof the hair
production�Graying is influenced by genetics�Graying in patches may indicate a nutritional deficiency.
forefinger.�Hold a few strands of hair
taut with one hand while youslide the thumb and forefingerof your other hand along thelength of the strand.
Maria Carmela L. Domocmat, RN, MSN
STEP 4
> Observe the amount and distribution of the hair
Male Pattern Balding
the hair throughout thescalp – varies with age, sex, and overall health.
Maria Carmela L. Domocmat, RN, MSN
STEP 5
Inspect thescalp for lesions.
Regions of infection will fluoresce when exposed
to the ultraviolet lightof a Wood’s lamp.lesions.
�Dim the room light and shine a Wood’s lamp on theclient’s scalp as you part the hair.
Maria Carmela L. Domocmat, RN, MSN
Palpation of Hair
1. Palpate the hair between your fingertips.fingertips.
2. Note the condition of the hair form the scalp to the end the hair.
Maria Carmela L. Domocmat, RN, MSN
Abnormalities of
Hair and Scalp
PediculosisPediculosisCapitis (head lice)
Maria Carmela L. Domocmat, RN, MSN
Hirsutism -excess body hair in females, following the male pattern. Typically due to endocrine or metabolic dysfunction, or idiopathic.
Side-effect ofCyclosporin
Maria Carmela L. Domocmat, RN, MSN
Alopecia Areata
Maria Carmela L. Domocmat, RN, MSN
Constant feature of Kwashiorkorbut may also be seen in Marasmus.
Dry hair; lacks normal lustre
Maria Carmela L. Domocmat, RN, MSN
The ‘flag-sign’ or signa de bandera
-alternating darker and lighter bands when held up.
Trichotillomania
Maria Carmela L. Domocmat, RN, MSN
Tinea Capitis
Seborrheic Dermatitis
Maria Carmela L. Domocmat, RN, MSN
Symptoms of Scurvy-hairs on most parts of the body become corksrew-shaped
Lanugo hair
Maria Carmela L. Domocmat, RN, MSN
Menke’s kinky hair syndrome
Sparse and brittle hairin this sex-linked disordercaused by a defect in caused by a defect in intestinal copper absorption
Maria Carmela L. Domocmat, RN, MSN
Assessing
thethe
Nails
Maria Carmela L. Domocmat, RN, MSN
Inspect nail grooming and cleanliness
STEP 1
STEP 2
Inspect nail color and markings.
Maria Carmela L. Domocmat, RN, MSN
STEP 3
Assess capillary refill
Maria Carmela L. Domocmat, RN, MSN
STEP 4
Inspect and
palpate the
nails for nails for
shape and
contour.Schamroth Technique
Maria Carmela L. Domocmat, RN, MSN
Curvature of the normal nail
Clubbing of the nail
Spoon nail
Maria Carmela L. Domocmat, RN, MSN
STEP 5
Palpate the nails to determine
thickness, regularity, and
attachment to the nail bed.
STEP 6
Inspect and palpate the cuticles.
Maria Carmela L. Domocmat, RN, MSN
Common Nail Disorders
Clubbing of the finger
In clubbing, the distal phalanx of each finger is roundedand bulbous. The nail plate is more convex, and the angle between the plate and the proximal nail fold increases to 180º or more. The proximal nail fold, when palpated, feels spongy or floating. Causes are many, including chronic hypoxia and lung cancer.
Maria Carmela L. Domocmat, RN, MSN
Paronychia
Maria Carmela L. Domocmat, RN, MSN
ONYCHOLYSIS
With Hyperkeratosis
Maria Carmela L. Domocmat, RN, MSN
Beau’s Lines
�Are transverse depressions in the nails associated with acute severe illness. The lines emerge from underthe proximal nail folds weeks later and grow graduallyout with the nails.
Maria Carmela L. Domocmat, RN, MSN
Terry’s
Nails�Mostly whitish with a distal band of reddish brown�Lunulae may not be visible�Seen with aging and people with chronic diseases
* Liver Cirrhosis* Congestive Heart Failure* Non-Insulin-Dependent Diabetes
Maria Carmela L. Domocmat, RN, MSN
Transverse White Lines Transverse White Lines (Mees’’Lines) �Curves are similar to those of the
lunula, not the cuticle, and may followan acute or severe illness.
Maria Carmela L. Domocmat, RN, MSN
Onycho-cryptosis
Psoriasis Subungal Hematoma
LongitudinalMelanonychia
Eggshell Nail Onychomycosis
Maria Carmela L. Domocmat, RN, MSN
Onychauxis OnychatrophiaLeukonychia
Onychophagy Onychorrhexis Pteryigium
Maria Carmela L. Domocmat, RN, MSN
Palpation of the Hair�TextureInspection of the Nails�Color�Shape and ConfigurationPalpation of the Nails�Texture�Texture
Maria Carmela L. Domocmat, RN, MSN