2. Skin
Also called integumentary system,
skin is body’s largest organ and has several
important functions, including:
.1
protecting the tissues from trauma and bacteria
.2
preventing the loss of water and electrolytes
from the body
.3
sensing temperature, pain, touch, and pressure
.4
regulating body temperature through sweat
production & evaporation
.5
synthesizing vitamin D
.6
promoting wound repair by allowing cell
replacement of surface wounds.
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3. Layers of the skin
skin consists of two distinct layers: the epidermis and
dermis.
Subcutaneous tissue lies beneath
تحت
these layers.
epidermis—outer layer—is made of squamous epithelial tissue.
It’s thin and contains no blood vessels.
two major layers of the epidermis are the stratum corneum—
most superficial layer— and the deeper basal cell layer
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4.
Dermis— thick, deeper layer of skin—consists of
connective tissue and an extracellular material
called matrix, which contributes to skin’s
strength. Blood vessels, lymphatic vessels, nerves,
and hair follicles are located in dermis, as are
sweat and sebaceous glands.
العرقية و الدهنية
Because it’s well supplied with blood, dermis
delivers nutrition to the epidermis. In addition,
wound healing and infection control take place in the
dermis.
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7. Effects of aging on skin and glands
As people age, skin functions decline and normal
changes occur.
As a result, elderly patients are more prone to skin
disease, infection, problems with wound healing,
and tissue atrophy.
Glands also change with age; sweat glands become
fibrotic and produce less sweat.
This drop in sweat volume decreases the body’s
ability to cool, increasing the risk for hyperthermia.
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8. How skin ages Change
Pigmentation
Thickness
Moisture
Turgor
Texture
Findings in elderly people
Pale color
Wrinkling, especially on the face, arms, and legs
Parchment
رقيق
like appearance, especially over bony
prominences and on the dorsal surfaces of the hands, feet, arms,
and legs
Dry, flaky
قشور
, and rough
خشن
“Tents” and stands alone,
especially if the patient is dehydrated
Numerous creases and lines
خطوط و تجاعيد
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9. Nails
What’s on your plate?
The nail plate is the visible, hardened layer that covers the
fingertip.
The plate is clear with fine longitudinal ridges
طولي بشكل
.
The pink color results from blood vessels underlying
vascular epithelial cells.
What is the matrix?
The nail matrix is the site of nail growth. It’s protected by
the cuticle
بشرة
.
At the end of the matrix is the white, crescent-shaped
area,
The lunula, which extends beyond the cuticle.
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10. Nails
Not hard as nails anymore
With age, nail growth slows and the nails become brittle
جاف
and thin.
هش
Longitudinal ridges in the nail plate become much more
pronounced
وضوحا
, making the nails prone to splitting
انقسام
. Also, the nails lose their luster
بريق
and become yellowed.
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11. Obtaining a health history
When assessing a problem related to skin, hair, or nails, you
need to thoroughly explore the patient’s chief complaint,
medical history, family history, psychological history, and
patterns of daily living.
Keep in mind that skin, hair, & nail abnormalities may result
from a medical problem related to the patient’s chief
complaint, but the patient may overlook or minimize them.
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12. Asking about the skin
Typical questions to ask about changes in a patient’s skin include:
How and when did the skin changes occur?
Are the changes in the form of a skin rash or lesion?
Is the change confined to one area, or has the condition
spread?
Does the area bleed or have drainage?
Does the area itch?
How much time do you spend in the sun, and how do you
protect your skin from ultraviolet rays?
Do you have allergies?
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13. Asking about the skin
Do you have a family history of skin cancer or other
significant diseases?
Do you have a fever or joint pain, or have you lost weight?
Have you had a recent insect bite?
Do you take any drugs or herbal preparations? If so, which
ones?
What changes in your skin have you observed in the past few
years?
What skin products do you use?
Have you recently changed or added new soaps, detergents, or
dryer sheets?
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14. Asking about the hair
Most concerns about the hair refer either to
hair loss or( hirsutism) an increased growth and
distribution of body hair.
Either of these problems can be caused by such
factors as skin infections, an or adrenal
الكظرية
tumors, increased stress, or systemic
diseases, such as hypothyroidism
الدرقية
and
malignancies.
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15. The root of the problem
To identify the cause of your patient’s hair problem, ask:
When did you first notice the loss (or gain) of hair? Was it
sudden or gradual?
Did the change occur in just a few spots or all over your
body?
What was happening in your life when the problem started?
Do you take any medications or herbal preparations? If so,
which ones?
Are you experiencing itching, pain, discharge, fever, or
weight loss?
What serious illnesses, if any, have you had?
Have you ever had hair replacements?
Have you ever experienced hair loss (or gain) before?
Do you use hair dye? How often?
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16. Asking about the nails
Most complaints about the nails concern changes in growth or
color. Either of these problems may result from infection,
nutritional deficiencies, systemic illnesses, or stress.
Typical questions to ask about changes in a patient’s nails
include:
When did you first notice the changes in your nails?
What types of changes have you noticed (for example, nail
shape, color, or brittleness)?
Were the changes sudden or gradual?
Do you have other signs or symptoms, such as bleeding, pain,
itching, or discharge?
What’s the normal condition of your nails?
Do you have a history of serious illness?
Do you have a history of nail problems?
Do you bite your nails?
Have you had nail tips attached?
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17. Assessing skin, hair, and nails
To assess skin, hair, and nails, you’ll use the
techniques of inspection and palpation.
Before beginning the examination, make sure the
room is well lighted and comfortably warm.
Wear gloves during your examination.
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18. Skin
Before you begin your skin assessment, gather these items:
A clear ruler with centimeter and millimeter, & a magnifying
glass, pin light, and clean gloves.
This equipment enables you to measure and closely inspect
skin lesions and other abnormalities.
Start by observing the skin’s overall appearance. Such
observation can help you identify areas that need further
assessment.
Inspect and palpate the skin area by area, focusing on color,
texture, turgor, moisture, and temperature.
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19. Texture and turgor
Inspect and palpate the skin’s texture, noting its
thickness & mobility. It should look smooth & be intact.
Rough, dry skin is common in patients with
hypothyroidism, psoriasis
الصدفية
, and excessive
keratinization.
Skin that isn’t intact may indicate local irritation or
trauma.
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20.
Palpation also helps you evaluate the patient’s hydration
الترطيب
status. Dehydration and edema cause poor skin
turgor.
However, because poor skin turgor may also be caused by
aging, it may not be a reliable indicator of an elderly patient’s
hydration status.
Over
hydration causes skin to appear edematous and spongy.
Localized edema can also result from trauma or systemic
disease.
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21. Moisture
Observe the skin’s moisture content. The skin should be
relatively dry, with a minimal amount of perspiration.
Skin-fold areas should also be fairly dry.
Overly moist skin can be caused by anxiety, obesity, or an
environment that’s too warm.
Heavy sweating, or diaphoresis, usually accompanies fever;
strenuous
شاق
activity; cardiac, pulmonary, and other
diseases; and any activity or illness that elevates metabolic
rate.
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22. Temperature
Palpate the skin bilaterally for temperature, which can
range from cool to warm. Warm skin suggests normal
circulation; cool skin, a possible underlying disorder.
Distinguish between generalized and localized coolness and
warmth. Localized skin coolness can result from
vasoconstriction associated with cold environments or
impaired arterial circulation to a limb.
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23.
Lesions
During your inspection, you may see normal variations in the
skin’s texture & pigmentation.
After you’ve identified the type of lesion, you’ll need to
describe its characteristics, pattern, location, and
distribution.
A detailed description can help you determine whether the
lesion is a normal or pathologic skin change.
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24. Hair
Start by inspecting and palpating the hair over the
patient’s entire body, not just on his head.
Note the distribution, quantity, texture, & color.
The quantity and distribution of head and body hair vary
between patients.
However, hair should be evenly distributed over the entire
body.
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25. Nails
Assessing the nails is vital for two reasons:
The appearance of the nails can be a critical indicator of
systemic illness, and their overall condition tells you a lot
about the patient’s grooming habits and ability to care for
himself.
Examine the nails for color, shape, thickness, consistency,
and contour
شكل محيط
.
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26. Abnormal findings
Various abnormalities may be found when assessing the skin,
hair, and nails.
Because these abnormalities may be visible to others, the
patient may experience some degree of emotional stress.
Carefully document all abnormal findings, health history,
and as much information as possible from the physical
examination.
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27. Skin abnormalities
The signs and symptoms you
detect during your assessment
may be caused by a wide
variety of disorders.
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28. Hair abnormalities
Alopecia
Alopecia occurs more commonly and extensively in men than in
women. Diffuse hair loss, although commonly a normal part of
aging, may occur as a result of pyrogenic
للحمى مولد
infections,
chemical trauma, ingestion of certain drugs, and
endocrinopathy and other disorders.
Hirsutism
Excessive hairiness in women, or hirsutism, can develop on the
body and face, affecting the patient’s self-image. Generalized
hirsutism can result from certain drug therapy or from such
endocrine problems as Cushing’s syndrome and acromegaly.
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29. Nail abnormalities
Although many nail abnormalities are harmless, some
point to serious underlying problems. Common nail
problems include Beau’s lines, clubbing, koilonychia.
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30. Clubbing
With clubbed fingers, the proximal edge of the nail elevates
so the angle is greater than 180 degrees.
The nail is also thickened and curved at the end, and the
distal phalanx looks rounder and wider than normal.
To check for clubbing, view the index finger in profile and
note the angle of the nail base.
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31. Terry’s nails
In patients with Terry’s nails, the nail beds are
white and look like ground glass.
The lunula can’t be seen. Terry’s nails may affect
one or all nail beds.
This finding commonly occurs with severe liver
disease.
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32. Onycholysis
Onycholysis is the loosening of the nail plate with
separation from the nail bed, which begins at the
distal groove.
It’s associated with minor trauma to long
fingernails and such disease processes as
psoriasis
صدفية
, contact dermatitis, hyperthyroidism,
& Pseudomonas infections.
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