Skin, Hair & Nails

• The integumentary system consists of the skin, hair, and nails, which are external structures that serve a variety of specialized functions
• Skin - largest organ of the body
• Skin contains cells responsible for producing melanin and keratin.
• Epidermis - the outermost layer of skin on your body
• Epidermis - protects your body from harm, keeps your body hydrated, produces new skin cells and contains melanin, which determines the color of your skin
• Dermis - Serves as a supporting matrix for nerve tissue, blood vessels, sweat and sebum glands, and hair follicles.
• Subcutaneous tissue- Functions as a storage site for fat, serving as an energy reserve
• Subcutaneous tissue- Acts as a cushion, offering protection to bones and internal organs.
• Subjective Data: COLDSPA

  C- Character

  O- Onset

  L- Location

  D- Duration

  S- Severity

  P- Pattern

  1A- Associated factors
• Normal skin color - colored skin tones without unusual or prominent discoloration
• Pallor - is seen in arterial insufficiency, decreased blood supply, and anemia
• Cyanosis - Dark skin may appear blue, dull, and lifeless in the same areas
• Jaundice - Characterized by yellow skin tones, ranging from pale to pumpkin, particularly of the sclera, oral mucosa, palms and soles
• Jaundice - client may have hepatitis
• Erythema - redness of the skin caused by hypermia
• Acanthosis - a velvety darkening of the skin in the body folds, creases, especially the neck, groin, and axilla.
• Is birthmark, vitiligo, albinism condition normal?

  Yes
• Skin Types: Very light, Celtic type

  Type 1
• Skin Types: Light-skinned European

  Type 2
• Skin Types: Light intermediate, or dark-skinned European

  Type 3
• Skin Types: Dark intermediate

  Type 4
• Skin Types: Mediterranean or olive skin

  Type 4
• Skin Types: Dark or brown type

  type 5
• Skin Types: Very dark, or black type

  Type 6
• Braden scale - tool to predict pressure sorerisk
• Push tool- to document the degree of the skin breakdown to provide a baseline to compare the degree
• Pressure ulcer Stage: Intact skin with nonblanchable redness of localized area usually over a bony prominence

  Stage 1
• Pressure ulcer Stage: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.

  Stage 2
• Pressure ulcer Stage: Pressure ulcer Stage: Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.

  Stage 3
• Primary skin lesions- arise from normal skin due to

  irritation or disease
• Secondary skin lesions- Arises from changes in primary lesions
• Secondary skin lesions- crusts, keloids, scars
• Macule - Small, flat, nonpapable skin color change that appears as a flat, smooth, and elevated area of skin
• Macule - lentigines, petechiae, scarlet fever
• Patch - may have irregular order like skin chloasma
• Papule - a small, raised, solid mass on the skin that is typically less than 0.5cm
• Plaque - a larger raised area on the skin that is typically more than 0.5 cm
• Nodule - a palpable, solid, rounded mass that is typically larger than a papule (0.5cm o 2cm)
• Tumor - a general term for a swelling or abnormal growth of tissue (greater than 1 to 2cm)
• Vesicle - a small, fluid-filled blister that is less than 0.5 cm