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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
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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
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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
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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
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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
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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).
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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.
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