Chapter 26 Assessment of the Skin, Hair, and Nails

Fibroblasts

Collagen is a protein formed by dermal cells that then produce ground substance, a protein lubricant that surrounds the dermal cells and fibers and contribute to the skins normal suppleness and turgor. The major component of elastic fiber (gives skin elasticity) is elastin.

obtained from intact primary lesions (bullae, vesicles, or pustules), if possible.

Cultures for bacterial infection

Always wear gloves. Using a tongue blade, gently scrape cells from skin lesions into a clean container and send to lab.

Cultures for fungal infection

A cotton-tipped applicator is used to obtain vesicle fluid from intact lesion. These are placed on ice immediately after collected and then transported to lab.

Cultures for viral infection (Herpes)

Apply an antibiotic ointment and place a sterile dressing on the incision.

A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity will the nurse assign to an LPN/LVN working with this client? A. Teach the client about signs of incisional infection. B. Instruct the client about how to do dressing changes. C. Apply an antibiotic ointment and place a sterile dressing on the incision. D. Complete the written discharge instructions for the long-term care facility.

Cultures for viral infections

A cotton-tipped applicator is used to obtain vesicle fluid from intact lesions. Tubes are placed on ice for transport to the lab.

Punch biopsy

A small, circular, cutting instrument, or "punch," ranging in diameter from 2 to 6 mm, is used. After the site is injected with a local anesthetic, a small plug of tissue is cut and removed. The site may be closed with one or two sutures

asymmetry of shape

ABCDE: What is A?

border irregularity

ABCDE: What is B?

color variation within one lesion

ABCDE: What is C?

diameter > 6 mm

ABCDE: What is D?

Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

ABCDE: What is E?

Excisional biopsy

Deep incisions are made and then sutured after the specimen is removed.

Warm red area on the calf

During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response? A. Clubbing of the nail beds B. Cool extremities C. Café au lait spots D. Warm red area on the calf

Protection, homeostasis (water balance) temperature regulation, sensory organ, vitamin synthesis, psychosocial

Functions of the Skin

Papules

Primary Lesions; small, firm, elevated lesions less than 1 cm (elevated moles, warts)

Plaques

Primary lesions: elevated, plateau-like patches more than 1 cm that do not extend into the lower skin layers

Vesicles

Primary lesions; blisters filled with clear fluid, less than 1 cm in diameter

Wheals

Primary lesions; elevated, irregularly shaped, transient areas of dermal edema (insect bites)

Nodules

Primary lesions; elevated, marble-like lesions more than 1 cm wide and deep

Macules

Primary lesions; flat lesions of less than 1 cm; moles/freckles; most often brown, white or red

Patches

Primary lesions; macules larger than 1cm in diameter

Pustules

Primary lesions; vesicles filled with cloudy or purulent fluid (acne and acute impetigo)

Erosions

Primary lesions; wider than fissures but involve only the epidermis; often associated with vessicles, bullae, or pustules

Shave biopsy

Removal of only the portion of the skin elevated above the surrounding tissue. A scalpel or razor blade is moved parallel to the skin surface to remove the tissue specimen. Shave biopsies are usually indicated for superficial or raised lesions.

annular

Ringlike with raised borders around flat, clear centers of normal skin

Crusts and oozing

Secondary lesions; are composed of dried serum or pus on the skin beneath which liquid debris may accumulate; crusts frequently result from broken vessicles, bullae, or pustules

Lichentification

Secondary lesions; are thickened areas of epidermis with accentuated skin markings. They are caused by chronic rubbing and scratching

Atrophy

Secondary lesions; characterized by thinning of the skin surface with loss of skin markings; skin is translucent and paper like (striae or "stretch marks")

Ulcers

Secondary lesions; deep erosions that extend beneath the epidermis and involve the dermis and sometimes the subcutaneous fat

Fissures

Secondary lesions; linear cracks in the epidermis, which often extend into the dermis (athlete's foot)

Scales

Secondary lesions; visibly thickened stratum corneum; appear dry and usually whitish; most often seen with papules and plaques

"I have been working in my garden for several hours every day."

The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? A. "Every morning, I check the biopsy site for signs of infection." B. "I have been cleaning my face with soap and water." C. "My appetite is improving lately." D. "I have been working in my garden for several hours every day."

Bathe the client, and apply a protective barrier to skin folds and perineum.

The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term care client who has areas of skin breakdown in the skin folds and the perineal area. Which intervention will be best for the RN to delegate to the nursing assistant? A. Check the client's skin weekly for areas of redness or breakdown. B. Teach the client and family about the importance of good hygiene in skin folds. C. Evaluate the client's ability to provide skin hygiene independently. D. Bathe the client, and apply a protective barrier to skin folds and perineum.

Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.

The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action will the nurse take first? A. Add potassium hydroxide to the specimen to check for a possible fungal infection, and inspect it under the microscope. B. Soak the crust of a possible bacterial lesion with normal saline. C. Instruct the client who has had a punch biopsy about wound care. D. Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.

Psoriasis

The nurse is assessing a client and observes multiple small pits in all of the client's fingernails. The nurse suspects that the client may have which condition? A. Cystic fibrosis B. Iron deficiency anemia C. Isolated periods of severe malnutrition D. Psoriasis

Presence of one of the ABCD features

The nurse is aware that which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? A. 1-mm ecchymotic area on the upper extremity B. Presence of one of the ABCD features C. Dark red color D. Round and raised appearance

"I use a tanning bed to avoid the sun's harmful rays."

The nurse is instructing the client on skin and sun protection. Which statement by the client indicates the need for further teaching? A. "My skin is better protected from the sun because I am dark skinned." B. "Sunscreen should be applied liberally." C. "I use a tanning bed to avoid the sun's harmful rays." D. "My sunglasses are UVA and UVB protected."

Body image counseling

The nurse is teaching the client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client? A. Body image counseling B. Respiratory protection C. Self-suctioning D. Tobacco cessation education

Checks the oral mucosa

The nurse notices yellowing at the corners of the sclera in the African-American client admitted for hepatitis. What does the nurse do next? A. Palpates the liver B. Checks the oral mucosa C. Examines the client's hair D. Monitors pulse oximetry

"How is this affecting you?"

The older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response? A. "How does this make you feel?" B. "How is this affecting you?" C. "Wear a hat outside to stay warm." D. "You could wear a wig."

Get help and lift the client.

The older adult immobile client has "sunk" to the bottom of the bed. What will the nurse do first? A. Gently pull the client up. B. Get help and lift the client. C. Look for broken skin areas. D. Pad the bony prominences.

Culture for fungal infections

Using a tongue blade, gently scrape scales from the skin lesions into a clean container and send to the laboratory for culture. Container may be kept at room temperature.

bleeding into the tissue is abnormal and results in purpuric lesions (bleeding under the skin that may progress from red to purple to brownish yellow), petechiae, and ecchymosis.

Vascular changes or markings that are classified as Abnormal

include birthmarks, cherry angiomas, spider angiomas, and venous stars.

Vascular changes or markings that are classified as Normal

Vascular changes or markings are classified as Abnormal

bleeding into the tissue is abnormal and results in purpuric lesions (bleeding under the skin that may progress from red to purple to brownish yellow), petechiae, and ecchymosis.

circular

circinate

Dermis (corium):

composed of connective tissue that contains no cells; composed of collagen and elastic fibers that give the skin flexibility and strength; has capillaries and lymph vessels for the exchanged of oxygen and heat; sensory nerves.

apocrine sweat glands

direct contact with hair follicle, mostly in axillae, nipple areola, periumbilicus, and perineal body areas, cause body odor due to skin bacteria and secretions.

sebaceous glands

distributed over the entire skin surface except for the palms and soles of feet. Produce sebum which is bacteriostatic, lubricates skin and reduces water loss.

Epidermis

does not have own blood supply, receives nutrients by diffusion from dermal layer

hirsutism

excessive growth of body hair or hair growth in abnormal body areas

Hair

follicles located in the dermal layer of skin but are actually extensions of the epidermal layer; stronger than skin keratin; stressors can alter hair growth.

Vascular changes or markings are classified as Normal

include birthmarks, cherry angiomas, spider angiomas, and venous stars.

coalesced

lesions that merge with one another and appear confluent

thickened

lichenfied

Dystrophic (abnormal appearing) nails

may occur with a serious systemic illness or local skin disease involving the epidermal keratinocytes.

Culture for Bacterial infection

obtained from intact primary lesions. Express material from the lesion, collect it with a cotton-tipped applicator, and place the material in a bacterial culture medium specified by the laboratory.

linear

occurring in a straight line

diascopy

painless technique that eliminates erythema caused by increased blood flow to the skin.

itching

pruritus

dandruff

really the cause of excessive oil

clustered

several lesions group together

Petechiae

small, reddish purple lesions that do not fade or blanch when pressure is applied. Indicate increased capillary fragility. Often occur in lower extremities with stasis dermatitis, a condition usually seen in patients who have chronic venous insufficiencies.

Stratum corneum

(horny layer) outermost skin

Asymmetry of shape Border irregularity Color variation within one lesion Diameter greater than 6 mm Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

Assess lesions following ABCDE features that are associated with skin cancer:

A multicolored lesion is present on the client's thigh.

When the nurse is assessing the skin of an older adult client, which of these data will be most important to report to the physician? A. A multicolored lesion is present on the client's thigh. B. Liver spots are present on both hands. C. Cherry hemangiomas are scattered on the client's back. D. The skin on the extremities is paper thin.

Administer an antihistamine to a client who is describing pruritus.

Which activity for the long-term care client does the nurse plan to assign to the LPN/LVN? A. Develop a care plan for a client who has blisters caused by herpes zoster. B. Administer an antihistamine to a client who is describing pruritus. C. Teach a client how to self-assess for changes in skin lesions. D. Perform a baseline skin assessment for a newly admitted client.

Asymmetry, border, color, diameter, evolving

Which method will the nurse use to assess skin lesions for cancer? A. American Cancer Society Skin Assessment B. Asymmetry, border, color, diameter, evolving C. Dermatologist skin review D. Size, location, and inflammation

Five clustered circumscribed lesions on the chest

Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? A. Clustered round lesions to the chest B. Five clustered circumscribed lesions on the chest C. Five diffuse circinate lesions on the chest D. Several lesions in one area that have well-defined borders

Pitting edema

Which skin condition will the emergency department nurse assess first? A. Localized redness to the surgical site B. Pitting edema C. Poor skin turgor D. Red bony prominences

"Administration of local anesthetic agents may cause burning."

While providing teaching to the client undergoing excisional biopsy, which statement will the nurse include? A. "Administration of local anesthetic agents may cause burning." B. "The biopsy results will be available within 2 hours of the procedure." C. "The dressing must remain in place for the first 48 hours." D. "Redness and swelling at the puncture site are expected."

handheld, long-wavelength ultraviolet light or Wood's light is sometimes used during a physical examination. Exposure of some skin infections produces a specific color such as blue-green or red.

Wood's light Examination

Keratinocytes

actual cells, capable of cell division are the basal cells. Produces Keratin

universal

all areas of the body involved, with no areas of normal-appearing skin

primary lesions

an initial reaction to a problem that alters one of the structural components of the skin.

secondary lesions

are changes in the appearance of the primary lesion.

eccrine sweat glands

arise from epithelial cells, found over entire body, odorless, important for temperature regulation.

circumscribed

well-defined with sharp borders

diffuse

widespread, involving most the body with intervening areas of normal skin; generalized

serpiginous

with wavy borders, resembling a snake