Skin, Hair, and Nails
DSN
Kevin Dobi, MS, APRN
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Concept represents structural intactness and
physiologic function of tissues and conditions that
affect integrity.
Tissues referred to: Skin, hair, and nails.
Interrelated concepts:
 Perfusion
 Oxygenation
 Motion
 Tactile sensory perception
 Elimination
 Nutrition
 Pain
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Integumentary system:
 Skin and accessory structures
 Hair
 Nails
 Sweat glands
 Sebaceous glands
Skin considered a body organ, an elastic, self-regenerating cover
for entire body
 Primary functions
 Protects the body from invasion.
 Protects internal body structures from physical trauma.
 Helps retain body fluids and electrolytes.
 Produces vitamin D.
 Helps regulate body temperature.
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Composed of three functionally related layers:
 Epidermis
 Dermis
 Subcutaneous layer (hypodermis)
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Thin, outermost layer of skin composed of stratified
squamous epithelium:
 Is avascular.
Stratum germinativum is deepest layer:
 Lies adjacent to rich supply of blood of dermis.
 Site of active cell generation.
 As new cells are produced, they push older cells
toward skin surface where they begin to die and
undergo process keratinization, causing cells to
become flat, hard, and waterproof.
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Stratum corneum is outermost aspect of epidermis:
Composed of 30 layers of dead, flattened, keratinized
cells.
 Exposed layer serves as protective barrier and regulates
water loss.
 Dead cells are continuously sloughed off and replaced by
new cells moving from the underlying epidermal layers.
 Process takes about 30 days.
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Contains melanocytes that secrete melanin:
Provides pigment.
 Shields from ultraviolet radiation.
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Dermis made up of highly vascular connective tissue.
 Thickness varies from 1 mm to 4 mm.
 Blood vessels dilate and constrict in response to heat
and cold, and to internal stimuli of anxiety or
hemorrhage, resulting in regulation of body
temperature and blood pressure.
 Dermal blood nourishes epidermis.
 Also contains sensory nerve fibers for touch, pain,
and temperature.
 Arrangement of connective tissue enables dermis to
stretch and contract with body movement.
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Subcutaneous tissue (hypodermis) is not actually skin
tissue, but a support structure for dermis and
epidermis.
 Acts as anchor for upper layers.
 Composed primarily of loose connective tissue
interspersed with subcutaneous fat.
 Fatty cells help retain heat and provide protective
cushion, and calories.
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Hair, nails, and glands (eccrine sweat glands, apocrine
sweat glands, and sebaceous glands) are considered
appendages.
Structures formed at junction of epidermis and dermis.
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Hair formed from epidermal cells in the dermis
Each hair consists of:
 A root
 A shaft
 A follicle (the root and it’s covering)
Base of follicle contains:
 Papilla
 A capillary loop
Melanocytes provide color.
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Nails are epidermal cells converted to hard plates of
keratin:
Composed of a free edge
 Nail plate
 Nail root (site of nail growth)
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The white crescent-shaped area at base, the lunula,
represents new nail growth.
Paronychium is tissue adjacent to nail.
 Cuticle is epidermal tissue (stratum corneum) growing on
nail plate at nail base.
 Tissue directly under nail is highly vascular and provides
clues to oxygenation status and blood perfusion.
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Eccrine sweat glands regulate body temperature by
water secretion through skin’s surface.
Most numerous and widespread sweat glands on
body.
Distributed almost everywhere throughout skin’s
surface:
 Greatest numbers on palms of hands, soles of feet,
and forehead.
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Apocrine sweat glands are much larger and deeper
than eccrine glands.
 Found only in axillae, nipples, areolae, anogenital
area, eyelids, and external ears.
Secrete odorless fluid containing protein,
carbohydrates, and other substances in response to
emotional stimuli.
Body odor is produced by decomposition of apocrine
sweat.
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Sebaceous glands secrete lipid-rich substance, sebum,
which keeps skin and hair from drying out.
Greatest distribution found on face and scalp; although
found in all areas of body except palms and soles
Sebum secretion, stimulated by sex hormone activity,
varies throughout lifespan.
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Do you have any chronic illnesses?
Do you take any medications?
 What do you take, and how often?
Have you noticed changes in the way your skin and
hair look or feel?
 Any changes in sensation of your skin?
What kind of work do you do?
To your knowledge, are you exposed to any chemicals
at home or work?
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Have you ever had problems with your skin such as
skin disease, infections involving skin or nails, or
trauma involving skin?
Has anyone in your family ever had skin-related
problems such as skin cancer or autoimmune-related
disorders such as systemic lupus erythematosus?
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Pruritus is most commonly reported symptom of skin
disease.
Other common problems related to skin:
 Rashes
 Pain/discomfort
 Lesions
 Wounds
 Changes in skin color or texture, hair, or nails
Complete symptom analysis:
 Onset
 Location
 Duration
 Characteristics
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When did itching first start?
 Did it start suddenly or over time?
 Where did it start?
 Has it spread?
Does anything make itching worse?
 Does anything relieve it?
 What have you done to treat it yourself?
What were the circumstances when you first noticed
itching?
 Taking any medications?
 Contact with possible allergens such as animals,
foods, drugs, plants?
Do you have dry or sensitive skin?
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When did rash start?
 Describe what it looked like initially: flat? raised?
 How long has rash been present?
Does it itch or burn?
 What makes it better? Worse?
 What have you done to treat it?
 Have you noticed other associated symptoms such as
joint pains, fatigue, or fever?
Do you have any known allergies?
Does anyone else in your family have a similar rash?
 Have you been exposed to others with a similar rash?
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Describe pain or discomfort:
 When did pain start?
 Where is it located?
 Does pain stay on skin surface, or go deep inside?
Describe pain or discomfort—sharp, dull, achy,
burning, itching:
 How bad on a scale of 0 to 10?
 Is pain constant, or does it come and go?
What triggers pain?
 What makes it worse?
 Better?
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Describe lesion you are concerned about. Where is
lesion?
 When did you first notice it?
 Do you have any symptoms associated with lesion
such as pain, discomfort, pruritus, or drainage?
Describe changes you have noticed in mole:
 Color
 Shape
 Texture
 Tenderness
 Bleeding
 Itching
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Has there been any generalized change in your skin
color?
 Yellowish tone?
 Paleness?
Have there been any localized changes in your skin
color?
 Redness?
 Discoloration of one or both feet?
 Areas of bruises or patches?
Vitiligo is loss of pigmentation in skin.
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In what way has the texture of your skin changed?
 Thinning
 Fragile
 Excessive dryness
Do you have excessively dry (xerosis) or oily
(seborrhea) skin?
 Seasonal, intermittent, or continuous?
 What do you do to treat it?
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Where is the wound located?
 What caused the wound?
 How long have you had it?
 Do you have associated symptoms such as pain or
drainage?
What have you done to treat the wound?
Do you typically have problems with wound healing?
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What changes or problems with your hair are you
experiencing?
 When did you notice the changes?
 Did the changes occur suddenly?
Can you think of any contributory factors?
 Have you recently experienced stress?
 Fever?
 Other illness?
 What kinds of hair products were used on your hair
recently?
Have you changed diet in the last few months?
Have you noticed any changes in distribution of hair
growth on your arms or legs?
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What kind of problem or changes do you have with
your nails?
 When did you first notice changes?
Have you been exposed to chemicals at home or work?
Are your nails brittle?
 Notice a pitting pattern to nails?
Have you ever had an infection of the nail or around
the nail bed?
Do you chew your nails?
Do you have difficulty keeping nails clean?
 Do your nails appear dirty?
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Routine techniques:
 Inspect for general color and uniformity of color.
 Consistent over body surface except vascular
areas.
 Whitish pink to olive tones to deep brown.
 Sun-exposed skin is darker.
 Note color, pigmentation, vascularity, bruising,
lesions, discolorations, or unusual odors.
 Systematically inspect and palpate skin from head
and neck to trunk, arms, legs, and back.
 Provide adequate lighting so that subtle changes are
not missed.
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Inspect skin for localized variations in color:
 Intentional: Tattoos, coining patterns.
 Normal localized variations: Pigmented nevi
(moles), freckles, patches, striae (stretch marks
secondary to weight gain or pregnancy).
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Palpate skin for texture, temperature, moisture,
mobility, turgor, and thickness.
 Texture: Smooth, soft, intact, even surface, with
calluses on hands, feet, elbows, and knees.
 Temperature and moisture: Warm and dry.
 Mobility and turgor: Should move easily when
lifted, with immediate return after released.
 Thickness: Varies with age and area.
 Palms and soles thickest.
 Eyelids thinnest.
 Callus: Thick from friction and pressure.
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Inspect and palpate scalp and hair for surface
characteristics, hair distribution, texture, quantity, and
color.
 Surface characteristics: Smooth without flaking,
scaling, redness, or lesions.
 Should be shiny and soft.
 Quantity and distribution: Balding patterns and
hair loss; male patterned.
Inspect facial and body hair for distribution, quantity,
and texture.
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Inspect for nails for shape, contour, color, consistency,
thickness, and cleanliness.
 Edges: Smooth and rounded.
 Contour: Flat and slightly rounded.
 Consistency: Note grooves, depressions, pitting, and
ridges.
 Color: Pink, blanched in light-skinned patients;
yellow or brown with vertical lines in dark-skinned
patients.
 Thickness: Smooth, uniform.
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Assessment of skin among infants and children follow
same general principals as described for adults.
Skin lesions common to infants and children include:
 Milia
 Erythema toxicum
 Diaper rash
 Rashes associated with allergens
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Acne is the most common and worrisome skin lesion
common to adolescents because of increases in
sebaceous gland activity.
Lesions are not only painful, but may also worry
patient because of personal appearance.
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Skin and hair undergo significant changes with aging.
Lesions are commonly found on older adults.
Although many lesions are considered expected
variations associated with the aging process, incidences
of skin cancer increase with age.
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Patients with limited mobility are at risk for skin
breakdown.
 Secondary to pressure and body fluid pooling
because of inability to feel pressure or decreased
ability to change position to relieve pressure.
 Examine patient’s skin, especially over bony
prominences, and turn patient so that complete skin
assessment may be performed.
Patients who operate wheelchairs are at high risk for
developing hand calluses; care should be taken to
examine patient’s hands.
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Assess all contact and skin pressure points for patients
who have limited mobility:
 When a red area of skin is noted, blanch skin by
applying gentle pressure over red areas.
 If skin becomes white when pressure applied and
resumes red appearance after pressure relieved,
circulation is sufficient and redness will disappear.
 If skin does not blanch when pressure applied, a
stage I pressure ulcer has developed.
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Pressure ulcers are staged as follows:
 Stage I = Prolonged redness with unbroken skin.
 Stage II = Partial-thickness skin loss appears as a
shallow, open ulcer with pink wound bed.
 Stage III = Full-thickness skin loss with damage to
subcutaneous tissue (may note serosanguineous
drainage).
 Stage IV = Full-thickness skin loss with exposed
bone, muscle, or tendon – may have some eschar or
slough.
 Unstagable = Eschar or slough may cover the entire
wound bed; thus, it is unstagable.
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Hyperkeratosis: Clavus (corn).
Dermatitis: Variety of superficial inflammatory
conditions:
Atopic: Superficial inflammation.
 Contact: Inflammatory reaction to irritant or allergen:
 Localized erythema.
 May weep, ooze, or crust.
 Seborrheic: Chronic inflammation:
 Scaly, white, or yellowish skin on scalp, eyebrows, ears,
axillae, chest, or back.
 Stasis: Inflammation seen mostly on lower legs of older
adults:
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petechiae,
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Psoriasis:
 Usually develops by age 20 years.
 Slightly raised erythematous plaques with silvery
scales.
 Mostly on elbows, knees, buttocks, lower back, and
scalp.
Pityriasis rosea:
 Acute, self-limiting disease of young adults in
winter.
 Thought to be viral.
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Lesions caused by viral infection:
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Warts – caused by HPV.
Herpes simplex – group of 8 DNA viruses.
 Outbreaks triggered by sun exposure, stress, fever.
 Grouped vesicles with an erythematous base.
 Very painful and highly contagious
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 Eruptions last about 2 weeks
Herpes varicella – Chickenpox
 Lesions erupt in crops
 Painful and highly contagious
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 Infectivity lasts about 6 days after final eruptions
Herpes zoster – Shingles
 Grouped lesions
along
sensory
nerve line
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Lesions caused by fungal infection:
 Tinea infections:
 Tinea corporis – Ringworm.
 Tinea cruris – “Jock itch.”
 Tinea capitis – scaling and balding.
 Tinea pedis – “Athlete's foot.”
 Candidiasis:
 Affect superficial layers of skin and mucous
membranes.
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Lesions caused by bacterial infection:
 Cellulitis – acute streptococcal or staphylococcal
infection of the skin and subcutaneous tissue.
 Impetigo – highly contagious Group A streptococcal
infection.
 Generally occurs on face, around mouth and nose.
 Folliculitis – inflammation of hair follicles.
 Furuncle (abscess or boil) – staphylococcal infection.
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Lesions caused by arthropods:
 Scabies – highly contagious mite Sarcoptes scabiei.
 Lyme disease – tick infected with Borrelia burgdorferi.
 Spider bites – majority from black widow or brown
recluse spiders.
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Basal cell carcinoma – most common:
 Locally invasive; rarely metastasizes.
 Nodular pigmented lesions with depressed center and
rolled borders.
Squamous cell carcinoma:
 Initially appears as a red, scaly patch.
Melanoma – most serious:
 Malignant proliferation of melanocytes.
 Irregularly shaped with color variations.
Kaposi’s sarcoma:
 Develops in connective tissue of immunosuppressed.
 Dark blue-purple macules, papules, nodules, and plaques.
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Bruise:
 Discoloration from blood seeping into tissues
resulting from trauma.
Bites
Burns
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Pediculosis (lice):
 Lice on the body are called Pediculosis corporis.
 Pubic lice are called Pediculosis pubis.
Alopecia areata:
 Chronic inflammatory disease of hair follicles
resulting in hair loss on scalp.
Hirsutism:
 Increase in growth of facial, body, or pubic hair in
women.
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Onychomycosis:
 Fungal infection of nail plate caused by Tinea
unguium.
Paronychia:
 Acute or chronic infection of cuticle caused by
staphylococci and streptococci, although Candida
may be causative organism.
Ingrown toenail:
 Occurs when nail grows through lateral nail and into
skin.
 Usually involves great toe.
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As the nurse performs a respiratory assessment, he notes a
mole on the patient’s back over the right scapula. What is
most important for the nurse to ask the patient?
A.
B.
C.
D.
“Do you sleep on your right side?”
“Does your bra strap rub this mole?”
“Has this mole changed recently?”
“Have you applied any creams to this mole?”
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A pustule is noted over the maxilla of the patient. Which of
the following illustrates a pustule?
A.
B.
C.
D.
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An 82-year-old patient is brought to the emergency department
with suspected broken right hip. It is believed that she was lying
between the bed and the wall for more than 48 hours before she
was found. As the nurse conducts an assessment, the following
condition over the lower back or coccyx area is seen. What
should the nurse document related to this finding?
Ecchymosis over coccyx
Scaling lesion with exudate over
coccyx
C. Stage 2 pressure ulcer
D. Stage 4 pressure ulcer
A.
B.
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Silas is a 2-year-old male child who attends day care. He
has eight siblings at his home. All of his immunizations are
up to date. He has a history of strep throat and RSV. His
favorite activity is block stacking. His mother reports that
he is generally a happy baby who is starting to become
potty trained.
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Subjective data:
 Complains of painful rash on R calf that is spreading to
lower legs.
 Mother says the rash has been there for 1 week.
 Mother admits to trying oatmeal baths to stop the pain,
but says this has not helped.
Objective data:
 Vital signs: T 96.4; P 71; R 14. Height: 2’0. Weight 40 lb.
 R calf has a dime-sized, honey-crusted sore.
 R calf has become increasingly more irritated over the
past week.
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Questions:
1. What risk factors does Silas have for impetigo?
2. What measures might have helped prevent
impetigo?
3. What should the nurse do in this clinical situation?
Prioritize actions.
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Sidney is a 4-year-old male child, who attends preschool.
He has five siblings at his home. All of his immunizations
are up to date. He has a history of otitis media and RSV.
His favorite activity is sandbox play. He reportedly plays
most of the day in the sandboxes at school.
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Subjective data:
 Complains of itching, circular, rash behind his left
ear.
 Mother says the rash has been there for 4 days.
 Mother admits to trying Vaseline to stop the itching,
but says this made it worse.
Objective data:
 Vital signs: T 97.2; P 68; R 16. Height: 4’0. Weight 70
lb.
 L ear rash has classic ring-worm shape with scaly
appearance that spreads to his hairline. No drainage.
The rash is quarter sized.
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Questions:
1. What risk factors does Sidney have for Tinea capitis?
2. What measures might have helped prevent Tinea
capitis?
3. What should the nurse do in this clinical situation?
Prioritize actions.
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