Health assessment of Skin

1. Health assessment of Skin

2. Structure of the Skin

3. Function • Preventing the passage of MO to skin & mucous membrane • Regulates the body temperature • Secretes sebum, an oily substance that softens and lubricate the hair and skin • Transmits sensation through nerve receptors • Produces and absorbs vitamin D in conjunction with ultraviolet rays from the sun. • F&E balance, absorption, excretion, immunity.

4. Epidermis; the outer layer of skin is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, stratum germinativum. • The outermost layer consist of dead, keratinized cells that render the skin waterproof. • The epidermis, hair, nail, dental enamel, & horny tissues are composed of keratin. It is replaced every 3-4 weeks.

5. The innermost layer of epidermis which called stratum germinativum is the only layer that undergoes cell division & contains melanin & keratin-forming cells. • Skin color depends on the amount of melanin & carotene" yellow pigment" contained in the skin & the volume of blood containing hemoglobin, the oxygen-binding pigment that circulates in the dermis.

6. Dermis; the inner layer of skin. It is connected to the epidermis by means of papillae. • These papillae from the base of the visible friction ridges that provide the unique pattern of fingerprints with which we are familiar. • The dermis is a well-vascularized connective tissue layer containing collagen & elastic fiber, nerve endings, and lymph vessels. It is also the origin of hair follicles, sebaceous glands, and sweat glands.

7. Sebaceous Glands; develop from hair follicles and, therefore are present over most of the body, excluding the soles and palms. • They secrete an oily substance called sebum that lubricate hair and skin and reduces water loss through the skin; it is also fungicidal and bactericidal effects.

8. Sweat Glands; two types; eccrine and apocrine. The eccrine glands are located over the entire skin surface & secrete an odorless, colorless fluid, the evaporation of which is vital to the regulation of body temperature. • The apocrine glands are concentrated in the axillae, perineum, & areola of the breast & usually open through a hair follicle. • They secrete milky sweat. The interaction of sweat with the skin bacteria produces body odor.

9. Subcutaneous Glands; merging with the dermis is the subcutaneous tissue, which is a loose connective containing fat cells, blood vessels , nerve, and the remaining portions of sweat glands and hair follicles. • The subcutaneous tissue assists with heat regulation & contains of vascular pathways for the supply of nutrients & removal of waste products from the skin.

10. The Langerhans’ cells of the epidermis, which bind antigen; the dermal dendrocytes of the dermis, which have phagocytic properties; & immune cells (T cells and mast cells), which are found in the dermis, contribute to the antigen-antibody responses affecting the skin.

11. Innervation and Blood Supply • The arterial vessels that nourish the skin form two plexuses (i.e., collection of blood vessels), one located between the papillary and reticular layers of the dermis and the other between the dermis and the subcutaneous tissue layer. • Capillary flow that arises from vessels in this plexus extends up and nourishes the overlaying epidermis by diffusion. • Blood leaves the skin by way of small veins that accompany the subcutaneous vessels. The lymphatic system of the skin, which aids in combating certain skin infections, also is limited to the dermis.

12. Manifestation of Skin Disorders

13. Lesions, Rashes, & Vascular Disorders • Rashesare temporary eruptions of the skin, such as those associated with childhood diseases, heat, diaper irritation, or drug-induced reactions. • Lesionrefers to a traumatic or pathologic loss of normal tissue continuity, structure, or function. • Rashes & lesions may range in size from a fraction of a mm (e.g., the pinpoint spots of petechiae) to many cms (e.g., decubitus ulcer)

14. Blister: a vesicle or fluid-filled papule. Blisters of mechanical origin form from the friction caused by repeated rubbing on a single area of the skin.

15. Pruritus • Pruritus, or the sensation of itch, is a symptom common to many skin disorders. • Generalized itching in the absence of a primary skin disease may be symptomatic of other organ disorders, such as chronic renal disease, diabetes, or biliary disease. • Warmth, touch, & vibration also can act locally to trigger the itch phenomenon.

16. Skin Damage Caused By Ultraviolet Radiation

17. Ultraviolet Rays Sunburn • Sunburn is caused by excessive exposure of the epidermal & dermal layers of the skin to UV radiation, resulting in an erythematous inflammatory reaction. Sunburn ranges from mild to severe. • A mild sunburn consists of various degrees of skin redness. • Severe sunburn is inflammation, vesicle eruption, weakness, chills, fever, malaise, and pain

18. Sunscreens & Other Protective Measures • The UV rays of sunlight or other sources can be either completely or partially blocked from the skin surface by sunscreens. • There are two primary types of sunscreens available on the market chemical (soluble) agents & physical (insoluble) agents. • Shielding the skin with protective clothing & hats or head coverings helps decrease ultraviolet radiation exposure.

19. Primary Disorders Of The Skin • Primary skin disorders are those originating in the skin. They include infectious processes, acne, allergic disorders & drug reactions, & arthropod infestations. • Although most of these disorders are not life threatening, they can affect the quality of life.

20. Infectious Processes- Fungal Infections • Fungi are free-living, saprophytic, plantlike organisms, certain strains of which are considered part of the normal skin flora. • The superficial mycoses, more commonly known as tinea or ringworm, invade only the superficial keratinized tissue (skin, hair, and nails). • Deep fungal infections involve the epidermis, dermis, & subcutis. Infections that typically are superficial may exhibit deep involvement in immunosuppressed individuals.

21. The fungi that cause superficial mycoses live on the dead keratinized cells of the epidermis. • They emit an enzyme that enables them to digest keratin, which results in superficial skin scaling, nail disintegration, or hair breakage, depending on the location of the infection.

22. Deeper reactions involving vesicles, erythema, & infiltration are caused by the inflammation that results from exotoxins liberated by the fungus. • Tinea pedis(athlete’s foot, or ringworm of the feet) is a common dermatosis primarily affecting the spaces between the toes, the soles of the feet, or the sides of the feet.

23. The lesions vary from a mildly scaling lesion to a painful, exudative, erosive, inflamed lesion with fissuring. Lesions often are accompanied by pruritus, pain, and foul odor. • Superficial fungal infections may be treated with topical or systemic antifungal agents. • Topical agents, both prescription and over-the-counter preparations, are commonly used in the treatment of tinea infections; however, outcome success often is limited because of the lengthy duration of treatment, poor compliance, & high rates of relapse at specific body sites.

24. Candidal Infections • Candidiasis (moniliasis) is a fungal infection caused by Candida albicans. This yeast-like fungus is a normal inhabitant of the GIT, mouth, & vagina. • Some persons are predisposed to candidal infections by conditions such as DM, antibiotic therapy, pregnancy, use of birth control pills, poor nutrition, & immuno-suppressive diseases. • Oral Candidiasis may be the first sign of infection with human immunodeficiency virus (HIV).

25. Acne • Acne is a disorder of the pilosebaceous unit (hair follicle & sebaceous gland). The hair follicle is a tubular invagination of the epidermis in which hair is produced. • The sebaceous glands empty into the hair follicle, & the pilosebaceous unit opens to the skin surface by means of a widely dilated opening called a pore

26. Atopic Eczema and Nummular Eczema • Atopic eczema (atopic dermatitis) is occurs in two clinical forms: infantile & adult. • It is associated with a type I hypersensitivity reaction There is a family history of asthma, hay fever, or atopic dermatitis. The infantile form is characterized by vesicle formation, oozing, & crusting with excoriations years. • Adolescents & adults usually have dry, leathery, & hyperpigmented or hypopigmented lesions located in the antecubital and popliteal areas.

27. These may spread to the neck, hands, feet, eyelids, & behind the ears. Itching may be severe with both forms. Secondary infections are common. • Treatment of atopic eczema is designed to target the underlying abnormalities such as dryness, pruritus, superinfection, & inflammation.

28. It involves allergen control, basic skin care, & medications. Because dry skin & pruritus often exacerbate the condition, hydration of the skin is essential to treating atopic dermitis. • Mild or healing lesions may be treated with lotions containing a mild antipruritic agent. • Treatment is palliative. Frequent bathing, foods rich in iodides and bromides, reduced stress, & increased the environmental humidity. • Topical corticosteroids, coal tar preparations, & UV light treatments are prescribed as necessary.

29. Urticaria • Urticaria, or hives, is characterized by edematous plaques, called wheals, that are accompanied by intense itching. Wheals typically appear as raised pink or red areas surrounded by a paler halo. • Histamine, released from mast cells, is the most common mediator of urticaria. It causes hyper-permeability of the microvessels of the skin and surrounding tissue, allowing fluid to leak into the tissues, causing edema and wheal formation.

30. A variety of immunologic, nonimmunologic, physical, and chemical stimuli can cause urticaria. • The most common causes of acute urticaria are foods or drinks, medications, or exposure to pollens or chemicals. Food is the most common cause of acute urticaria in children. • Physical urticarias constitute another form of chronic urticaria. Physical urticarias are intermittent, usually last less than 2 hours, are produced by appropriate stimuli, have distinctive appearances and locations, and are seen most frequently in young adults.

31. Other types of physical urticaria are cholinergic (i.e., exercise-induced), cold, delayed pressure, solar (i.e., sunlight), aquagenic (i.e., water), vibratory, & external (localized heat-induced). • Appropriate challenge tests (e.g., application of an ice cube to the skin to initiate development of cold urticaria) are used to differentiate physical urticaria from chronic urticaria due to other causes.

32. Subjective History Data (what the patient tells you) • Collect data about current "These information obtained symptoms provides clues to theclient’s • Client's past and family history • Life style and health practices overall level offunctioningin relation to skin, nail, & hair

33. Interview Approach • Ask questions in a straightforward manner. • Keep in mind that a nonjudgmental and sensitive approach is needed if the client has abnormalities • Explore symptoms from the client with a symptom analysis. Use COLDSPA as a guide.

34. CHARACTER: Describe the sign or symptom. How does it feel, look, sound, smell, and so forth? • ONSET: When did it begin? • LOCATION: Where is it? Does it radiate? • DURATION: How long does it last? Does it recur? • SEVERITY: How bad is it? • PATTERN: What makes it better: What makes it worse? • ASSOCIATED FACTORS: What other symptoms occur with it?

35. Nursing History

36. History of current symptoms • Because of differences in education, language, or cultural background, some clients may provide vague or confusing answers. • Be sure to state questions clearly and use words that the client can understand; avoid medical jargon. • Changes in sensation may indicate vascular or neurologic problems such as DM or arterial occlusive disease. Sensation problems may put the client at risk for developing pressure ulcers.

37. Uncontrolled body odor or excessive or insufficient perspiration may indicate an abnormally with the sweat glands or an endocrine problems such as hypothyroidism or hyperthyroidism. • Poor hygiene practices may account for body odor, and health education may be indicated. Perspiration decreases with aging because sweat glands activity decreases.

38. Examples of suggested questions • Are you experiencing any current skin problems such as rashes, lesions, dryness…etc? • Describe any birth marks or moles you now have? • Have you noticed any change in your ability to feel pain, pressure, light touch, or temperature changes? • Do you have trouble controlling body odor? How much do you perspire?

39. Past History • Current problems may be recurrence of previous ones. • Various types of allergens can precipitate a variety of skin eruption • Some skin rashes or lesions may be related to viruses or bacteria. • Family History • Acne, and atopic dermatitis tend to be familiar • A genetic component is associated with skin cancer.

40. Previous problems with the skin, nail, and hair including any treatment or surgery and its effectiveness? • Allergic skin reactions to food, medication, plants, or other environmental substances?

41. Lifestyle and Health Practices • Sun exposure can cause premature aging of skin and increase risk of cancer. • Older, disabled, or immobile clients who spend long periods of time in one position are at risk for pressure ulcer. • Extreme temperature affects the blood supply to the skin, and can damage the skin layers. • Regular habits provide information on hygiene and life style. The products used may be also being a cause of abnormality. Improper nail-cutting technique can lead to ingrown nails or infection.

42. Decreased flexibility and mobility may impair the ability of some elderly clients to maintain proper hygiene practices, such as nail cutting, bathing, and hair care • A balanced diet is necessary for healthy skin, hair, and nails. Adequate fluid intake is required to maintain skin elasticity. • Skin, hair, or nail problems, especially if visible, may impair the client's ability to interact comfortably with others because of embarrassment or rejection by others. • Stress can cause or exacerbate skin abnormalities • If clients do not how to inspect the skin, teach them how to recognize suspicious lesions early.

43. Objective Data (what we see, smell, hear & feel) • Color-freckles, moles, birthmarks. Color changes (erythema, pallor, cyanosis, jaundice). • Temperature. Moisture. Texture. Thickness. Edema • Turgor. Bruising. Lesions (note color, elevation, pattern, size, location, and any exudate)

44. Assessment of the skin, involves inspection and palpation. The entire surface may be assessed at one time or as each aspect of the body is assessed. • The nurse may need to use the olfactory sense to detect unusual skin odors; these are usually most evident in the skin folds or in the axillae. • Pungent body odor is frequently related to poor hygiene, hyperthyroidosis” excessive perspiration”.

46. The skin first assessed for color. Look for localized areas of bruising, cyanosis, pallor, & erythema. Check for uniformity of color & hypopigmentation or hyperpigmentation areas. • Place exposed to the sun may show a darker pigmentation than other areas. Remember that color changes may look different in dark-skinned people.

47. Palloris the result of inadequate circulation blood or hemoglobin and subsequent reduction in tissue oxygenation. It may be difficult to determine in clients with dark skin. • It is usually characterized by the absence of underlying red tones in the skin and may be most readily seen in the buccal mucosa. • Cyanosis; a bluish tinge is the most evident in the nail beds, lips, & buccal mucosa. In dark-skinned clients, close observation of the conjunctiva & palms & soles may show evident of cyanosis.

48. Jaundicemay first be evident in thesclera of the eyes & then in the mucous membranes & the skin. • Edema is the presence of excess interstitial fluid. An area of edema appears swollen, shiny, & taut & tends to blanch the skin color, or, if accompanied by inflammation, may redden the skin. • Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or vein abnormalities.

49. If possible and the client agrees, take a digital or instant photograph or significant skin lesions for the client record. Include a measuring guide” ruler or tape” in the picture to demonstrate lesion size. • Hemoglobin, which circulates in the red cells and carries most of the oxygen of the blood, exists in two forms. Oxyhemoglobin, a bright red pigment, predominates in the arteries and capillaries.

50. An increase in blood flow through the arteries to the capillaries of the skin causes a reddening of the skin, while the opposite change usually produces pallor. • The skin of light-colored persons is normally redder on the palms, soles, face, neck, and upper chest. • As blood passes through the capillary bed, some of the oxyhemoglobin loses its oxygen to the tissues & changes to deoxyhemoglobin—a darker & environment.