Assessment of hair, nails, neck, head in injections.
Anatomy and physiology of the skin
Subcutaneous fat - fat cells as an energy reserve also act as heat insulators, absorb shock and protect against injury
Dermis - layer above the fat layer all connective tissue that contains no cells - collagen and elastic fibers to give flexibility and strength. Fibroblasts - form scars, give turgor of the skin. Exchange of oxgen and heat, sensations of touch, pressure, temp. pain, itch.
Epidermis - outer layer. protective barrier between the body and environemnt. Resceives nutrients by defusion. Keratinocytes constantly devide to form new layers of skin, waterproof. Where vit D is activated. Melanocites give color to the skin. Protects the skin form UV.
A&P of the Hair
Hair folicals located in the dermal layer of the skinbut are actually extension ofthe epidermal lyaer. with in each folicle is a round column of keratin forms the hair shaft. Hair color - by rate of melanin production
A & P of the nails
also the extension of epidermis keratin produced. Pink color - reach blood supply
in light skinned clients; estreme paleness; skin appears white; loss of pink or yellow tones. In dark skined clients: a loss of red tones.
Associated with poor circulations or anemia. Asses oral mucouse membranes, nail beds, palms and soles of feet.
a blue gray coloration of the skin often described as ashen.
Central cyanosis: lips, tonegue, mucouse membranse, and facial features and associated with hypoxia.
rennened area associated with rashes, skin infections, prolonged pressure on the skin.
Bruised(blue-green-yellow) area. Interal bleeding, side effect of med, bleeding disorder. Does not blench
Tiny, pinpoint red or reddish-purple spots. From extravasation: leakage from vesseles from blood into the skin. Same as purpura and ecchymoses
Indicate increased capillary fragility
Bluish marbling. Occures in lights0skinned clients, especially when cold.
refers to the elasticity of the skin, which tells about hydration data.Pinch skin over a clavicle or the back of the hand.
Tenting: skin that staid piniched for a few seconds
escessive ammount of fluid in the tissues. Common in gocnegstive heart failure, kidney disease, peripheral vascular disease, or low albumin levels.
Assessing Edema: Trace- minimal depression is noted with pressure.
+1 --2mm depression, rapid return
+2 4mm disappears in about 10-15 sec
+3 6mm lasts 1-2 min The area appers slwallen
+4 8mm for 2-3 min, area is grossly edematous
Localized: inflamatory response, trauma
Pitting: FLuid and electrolite imbalance. Ambuatory - drusum of foot and medial ankle. Congestive heart failure and ranal disease. Venouse and cardiac insuficiency - bedridden: buttocs, sacrum, and lower back in hepatic cirrhosis and venous trhombosis or stasis
Nonpitting: Endocrine imbalance - generalized but more easily seen over tibia in hypothyroidism
variations in pigment or break in continuous tissue. ex. crusts that form from reptured pustules. Evaluae it for size, shape, pattern, color, distribution, texture(smooth, rough, scaly), surface relationsip(flat, raised, is it attached or mobile), exudate(drainage?odor), tenderness, pain or itching.
Assess for malignensy use ABCDE
B Border irregularity
C Color variations
D diameter 0.5 cm and bigger
Terms to descibe Lesions in Med-Surg book on page 471 table 26-3
moisture of the skin
Xerosis: excessive dryness
Diaphoresis: excessive moisture
smooth, think, shiny skin with no heir
Thick, rough skin
Integrity of the skin
thorough examinining areas with actula breaks or open areas.
describe breaks in skin integrity by their location, size, color and distribution and presenc eof darinage or any signs of infection.
Evaluate cleanliness of the skin; hair, nails, skin for soiling and offensive odor.
Assessing the Hair
Inspection and palpation
Assess scal phair and bod hair
Inspet hair for color, quality, distribution,condition of scalp, and presence of lesions, and presence of lesions or pediculosis(bshivost')
Hirsutism: excess facial or trunk hair
Alopecia: hair loss
Palpate texture of the hair (fine, medium, coarse)
Palpate the scalp for mobility and tenderness (lessions, tenderness, scars)
amount ( sparse-redkii, thick)
dry and coarse - hypothyroidism
thin and silky - hyperthyroidism
Assessing the Nail
Color: pale or cyanotic nail beds - circulatory or respiratory disorders result in anemia or hypoxiya
Capillary refill: good circulation to the extrimities in 2-3 seconds. Press end of the finger if nail poish is present