HA#7

• Epidermis


  Outermost layer of skin, contains stratum corneum, stratum lucidum, stratum granulosum and stratum germinativum
• Stratum germinativum (basal cell layer)


  • Mitosis occurs here
  • Contains melanocytes, producing melanin
• Stratum corneum


  • As cells rise, they die and their cytoplasm is converted to keratin, which has a rough, horny texture
  • This layer undergoes constant shedding
• Dermis


  • Mostly connective tissue, primarily collagen
  • Provides support and nourishment of epidermis
  • Contains blood vessels, nerves, muscle, sweat glands, sebaceous glands, hair follicles
• Sebaceous glands


  • Produce sebum through hair follicles, which make skin oily
  • Prevent water loss
• Sweat glands


  • Eccrine - smaller, coiled tubules which open to skin surface and located over the entire skin
  • Apocrine - larger, open to hair follicles, located mainly in axillae, areolae of the breasts and genital area, produce thick secretions which react with bacteria on skin surface to produce body odor
• Subcutaneous Layer (Hypodermis)


  • Consists mostly of fat
  • Provides protection, insulation, and caloric source
• Hair


  • Composed of keratin
  • Can be fine (vellus hair) or darker and thicker (terminal hair)
• Nails


  • Composed of keratin
  • Clear with highly vascular bed of epithelial cells underneath

  
• Infants


  • Lanugo - fine soft hair present at birth
  • Skin is thinner, less fat - more prone to dehydration and hypothermia
• Pregnancy


  • Linea nigra - line down midline of abdomen
  • Chloasma - face of pregnancy
  • Striae gravidarum - stretch marks
• Aging


  • Stratum corneum thins, loss of collagen, elastin, and fat, decrease of sebaceous and sweat glands
  • More prone to dehydration and hypothermia
• History of skin disease - what was it? how was it treated? does it run in the family?
• Significant familial predispositions - allergies, hay fever, psoriasis, eczema, acne
• Use of nonsterile equipment for tattoos increases risk of Hep C
• Change in pigmentation might suggest systemic illness (jaundice)
• Change in a mole
• Pruritus - any dryness? is it seasonal? (xerosis - dry, seborrhea - oily)

  
• Excessive bruising - consider abuse, frequent minor trauma may be sign of alcohol abuse
• Rash or lesion - onset, location, spread, character or quality, duration, associative factors, alleviating and aggravating factors, patient's perception
• Medications - prescription and over-the-counter, may indicate allergy to medication
• Hair loss or growth - gradual or sudden, hirsutism - unusual growth
• Change in nails
• Exposure to hazards - environmental or occupational, bitten by bee, tick, mosquito? exposure to plants or animals?
• Self-care - what cosmetics, soaps, chemicals? possible allergies
• Physical Examination - Color

  • General pigmentation should be even throughout
  • Benign pigmented areas - freckles (macules) on sun exposed skin, nevi (moles) - junctional, compound, dysplastic, birthmarks
  • Vitiligo - absence of melanin in patchy areas
• Pallor


  • Pale, white color caused by decrease of blood flow (vasoconstriction) or decrease in hemoglobin
  • Brown skinned people will be more yellow, black skinned people will be more gray
  • Palpebral conjunctiva and nail beds should be observed
  • Caused by shock, anemia
• Erythema


  • Redness due to increased blood flow (vasodilation)
  • If fever suspected, check skin for warmth. If edema, check skin for tightness
  • May be caused by fever, inflammatory process, emotions, CO poisoning
• Cyanosis


  • Bluish, purplish hue due to decreased perfusion of tissues
  • Darker skinned people have normal bluish tone on lips, palms, but not clearly evident, other clinical signs should be observed
  • May be caused by hypoxemia due to heart failure, shock, chronic bronchitis
• Jaundice


  • Yellow, orange hue due to jaundice (increased bilirubin in blood)
  • Hard and soft palate must be observed in addition to sclera of eyes
  • Dark urine also present
  • Due to liver problems such as hepatitis, cirrhosis
• Temperature


  • Check skin with dorsa of hands, hyperthyroidism may cause increase of temp
• Moisture


  • Diaphoresis may occur during fever or exercise
  • Dehydration can be observed by dry mucous membranes in mouth and cracked skin
• Mobility and Turgor


  • Mobility is ease of skin rising when pinched, turgor is returning back to its place
  • Slow turgor can be indicative of dehydration, "tenting" if severe dehydration
• Lesions


  • Any traumatic or pathological change in skin
  • Roll nodule gently between fingers to assess depth
  • Ultraviolet light is used if fungal infection suspected (Wood's light)
• Edema


  • The presence of excess interstitial fluid; an area that appears swollen, shiny and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin
  • It may also described as pitting or non-pitting edema
• Pressure Ulcers


  • Injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin
  • They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time
• Nursing Responsibility for Pressure Ulcers

  1. Use repositioning schedules (every 15 minutes when on chair or every 2 hours when on bed)

  2. Use pressure mattress or chair cushion

  3. Use lifting devices as directed to reduce shear (trapeze bar for patients, or lifts for family, if necessary)

  4. Use positioning with pillows or wedges to avoid bony prominence contact with surfaces and to maintain body alignment

  5. For those who are bedbound, avoid elevating the head of bed beyond 30 degrees except for brief periods