N260-Chapter 13

  1. Describe the structures and functions of the skin.
    • The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration.
    • Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.
    • Skin- epidermis, dermis, subcutaneous layers
  2. Obtain an accurate nursing history of the clients skin, hair, and nails.
    • Past History
    • Previous problems with skin, hair, nails
    • Allergic reactions
    • Family history of skin problems or skin cancer
    • Lifestyle and health practices
    • Exposure to sun or chemicals
    • Daily care of skin, hairs, nails
    • Usual diet and exercise patterns
  3. Explain how to prepare the client and the equipment necessary to perform a skin, hair, and nail assessment.
    • Note any distinctive odor
    • Generalized color variations
    • Skin breakdown
    • Primary, secondary, or vascular lesions
  4. Describe the two physical examination techniques used to assess the skin.
    • Inspection:
    • Note any distinctive odor
    • Generalized color variations
    • Skin breakdown
    • Primary, secondary, or vascular lesions
    • Palpation:
    • Lesions
    • Texture
    • Temperature and moisture
    • Thickness of skin
    • Mobility and turgor
    • Edema
  5. Assess the skin for color, breakdown, lesions, moisture, turgor, and edema.
    • if the skin/nail beds are not blue (cyanotic), we know the person is getting enough oxygen
    • If the skin is dry, we know that the person is underhydrated (dehydrated).
    • If the skin is moist, or hot, we know that the person is embarrassed, has just finished exercising, or may have a fever.
    • If the skin is itching, the person may have had a reaction to prescription medication or may have poison ivy
    • Skin and the tissues below the skin can also be a place that water collects. This is called edema or swelling
  6. Inspection and palpation for hair:
    • General color and condition, cleanliness, dryness or oiliness, parasites, and lesions
    • Amount and distribution of scalp, body, axillae, and pubic hair
    • Inspect hair shafts for nits or lice. It is not normal to have lice.
    • Inspect the scalp for dryness/flaking (seborrhea=dandruff).
  7. Inspection and palpation for Nails:
    • Inspect the nails from the side. The normal angle of the nail base is 160
    • Flattening of the nail beds or clubbing is NOT normal
    • Capillary refill is measured by depressing the nail edge(s) and then releasing.
    • Normal refill is immediate & indicates good blood circulation.
Card Set
N260-Chapter 13
Chapter 13 Skin, hair and nails