NURS 6512 Week 4 Assessment of the Skin, Hair, and Nails Assignment

NURS 6512 Week 4 Assessment of the Skin, Hair, and Nails Assignment

NURS 6512 Week 4 Assessment of the Skin, Hair, and Nails Assignment

Week 4: Assessment of the Skin, Hair, and Nails

Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.

This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.

Learning Objectives

Students will:

  • Apply assessment skills to diagnose skin conditions
  • Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
  • Apply assessment skills to collect patient health histories

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

  • Chapter 9, “Skin, Hair, and Nails”
    This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

This section explains the procedural knowledge needed prior to performing various dermatological procedures.

Chapter 1, “Punch Biopsy”

Chapter 2, “Skin Biopsy”

Chapter 10, “Nail Removal”

Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”

Chapter 16, “Skin Tag (Acrochordon) Removal”

Chapter 22, “Suture Insertion”

Chapter 24, “Suture Removal”

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.

Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

  • Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)

VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals

This interactive website allows you to explore skin conditions according to age, gender, and area of the body.

Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282.

Document: Skin Conditions (Word document)

This document contains five images of different skin conditions. You will use this information in this week’s Discussion.

Document: Comprehensive SOAP Exemplar (Word document)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Document: Shadow Health Support and Orientation Resources (PDF)

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Document: Student Acknowledgement Form (Word document)

Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.

Document: DCE (Shadow Health) Documentation Template for Health History (Word document)

Use this template to complete your Assignment 2 for this week.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 6, “The Skin and Nails”
In this chapter, the authors provide guidelines and procedures to aid in the diagnosis of skin and nail disorders. The chapter supplies descriptions and pictures of common skin and nail conditions.

Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from https://web.archive.org/web/20170215015223/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/absorbable_suture_chart.pdf

Ethicon, Inc. (2006). Dermabond topical skin adhesive application technique. Retrieved from https://web.archive.org/web/20150921174121/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_application_poster.pdf

Ethicon, Inc. (2001). Ethicon needle sales types. Retrieved from https://web.archive.org/web/20150921171922/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/needle_template.pdf

Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from https://web.archive.org/web/20150921202525/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/suture_chart_ethicon.pdf

Ethicon, Inc. (2002). How to care for your wound after it’s treated with Dermabond topical skin adhesive. Retrieved from https://web.archive.org/web/20150926002534/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_wound_care.pdf

Ethicon, Inc. (2005). Knot tying manual. Retrieved from https://web.archive.org/web/20160915214422/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/knot_tying_manual.pdf

Ethicon, Inc. (n.d.-c). Wound closure manual. Retrieved from http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure_Manual.pdf

Required Media 

Module 3 Introduction
Dr. Tara Harris reviews the overall expectations for Module 3. Consider how you will manage your time as you review your media and Learning Resources for your Discussions, Case Study Lab Assignments, DCE Assignments, and your Midterm exam (12m).

Skin, Hair, and Nails – Week 4 (19m)

Online media for Seidel’s Guide to Physical Examination

In addition to this week’s media, it is highly recommended that you access and view the online resources included with the text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and nails.

Note: To access the online resources included with the text, you need to complete the FREE online registration that is located at https://evolve.elsevier.com/cs/product/9780323172660?role=student .

To Register to View the Content

  1. Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student
  2. Enter the name of the textbook, Seidel’s Guide to Physical Examination (name of text without the edition number) in the Search textbox.
  3. Complete the registration process. NURS 6512: Week 4: Assessment of the Skin, Hair, and Nails Assignment

To View the Content for this Text

  1. Go to https://evolve.elsevier.com/
  2. Click on Student Site.
  3. Type in your username and password.
  4. Click on the Login button.
  5. Click on the plus sign icon for Resources on the left side of the screen.
  6. Click on the name of the textbook for this course.
  7. Expand the menu on the left to locate all the chapters.
  8. Navigate to the desired content (checklists, videos, animations, etc.).

Note: Clicking on the URLs in the APA citations for the Resources from the textbook will not link directly to the desired online content. Use the online menu to navigate to the desired content.

Suturing Tutorials

The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques

Tulane Center for Advanced Medical Simulation & Team Training. (2010, July 8). Suturing technique [Video file]. Retrieved from https://www.youtube.com/watch?v=c-LDmCVtL0o

Note: Approximate length of this media program is 5 minutes.

Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical mattress, horizontal mattress [Video file]. Retrieved from https://www.youtube.com/watch?v=MFP90aQvEVM

Note: Approximate length of this media program is 9 minutes.

Incision and Drainage of an Abscess (a common procedure in primary care)

New England Journal of Medicine (NEJM). (2013, September 30). NEJM abscess incision and drainage [Video file]. Retrieved from https://www.youtube.com/watch?v=MwgNdrA18fM&list=PL9UKTUFtRDcNq4–Vf2NYfUANEyObfeNm&index=8

Note: Approximate length of this media program is 10 minutes.

Dermablade Use for Shave Biopsies

Dermablade®. (2012, November 9). PersonnaBlades [Video file]. Retrieved from https://www.youtube.com/watch?v=D8u1Y18L9DQ

Note: Approximate length of this media program is 5 minutes.

Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.

Assignment 3 (Optional) Practice Assessment: Skin, Hair, and Nails Examination

Advanced practice nurses are required to have the skills and knowledge necessary to perform many different physical assessments and health examinations. In this course, you will demonstrate your abilities in this area by conducting various optional examinations on a volunteer “patient.”

In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice conducting an assessment of the skin, hair, and nails this week.

Differential Diagnosis for Skin Conditions Sample Student Work

Image no. 1- Split Nail

a.     Onychoschizia

Abnormal Physical characteristic

The skin disease causes the nails to split, flake, and crumble. The problem presents as onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails (Chessa et al., 2019).

  1. Brittle, soft, splitting toe nails that can easily
  2. Horizontal splitting of the
  • Nail fragility causes lamellar splitting of the nail plait (Sparavigna et , 2019).

The clinical presentation based on the observation of the image (number 1 in the lab assignment graphics), the patient is suffering from onychoschizia. The selection is justified by the lamellar splitting of toenail. Chessa et al. (2019) state that the two forms of nail plate brittleness are the idiopathic or brittle nail syndrome and secondary ones caused by general conditions. The lab graphic represents the primary form known as brittle nail syndrome.

Differential Diagnosis

  1. Nail Psoriasis

Researchers argue that psoriasis is the skin condition that most frequently affect nails (Haneke et al., 2017). The disease causes various observable clinical alterations in the nail structure.

  1. There are psoriatic pits caused by irritation of the apical
  • Red lunulae or severe nail dystrophy as a result of the involvement of the whole
  1. The destruction of the nail depends on the extent of the
  2. In some cases, there is pustular psoriasis observable as yellow spots under the
  3. Characterized by altered look of the toe nails. According to Haneke et al. (2017), the prevalence of nail psoriasis is between 1 and 2% of the world population, although up to 90% of all psoriatis have nail alterations over the
  • The nails may grow thick and start developing pinprick holes
  • The toenails ultimately change color or shape, start feeling tender and

c.     Onychomycosis

A nail infection caused by fungi such as dermatophytes, nondermatophytes, and yeast (Lipner & Scher, 2018). Onychomycosis is a common nail disorder which is clinically characterized by thickening of the toenails and onycholysisis. In other cases, there are observed buildup of debris in the space created after the nail has separated from the nail plate.

Additionally, there are color changes in the nail, usually yellow-brown or white.

d.     Nail Trauma

The main cause of nail trauma is blunt injury to the toe or fingernail. The injury causes blood clot under the nail in what is clinical termed as subungual hematoma. Other observed changes included discoloration, the nail lifting away from the nail bed as well as thickening.

Furthermore, the various forms that can be observed include lacerations and avulsions of the matrix tissue after an injury to the nail bed.

e.     Onychorrhexis

The patient has vertical ridges on the nails instead of the relatively smooth toenail. The condition may be caused by frequent use of nail polish remover, psoriasis, and eczema. The distinguishing clinical features with onychoschizia are up-and-down (longitudinal) lines on the fingernails. Onychoschizia affects all nails, with vertical splitting, not just ridges on the nail from the nail plate.

f.      Trachyonychia

The skin condition is closely associated with onychoschizia but differs due to signs like sever accentuation of longitudinal ridging with tiny adherent scales. The nails appear rough as if they are sandpapered.

SOAP Note

Chief Complaint (CC): Itching effect around the fingernail for more than two weeks.

History of Present Illness (HPI): Pudesh is a 63 year old Hispanic American who presents with itching that is frequent around the finger nails. The patient complains of dryness of the skin around the fingernails and discoloration (reddish) after scratching. The problem become worse when he started noticing a horizontal split between layers of te nail plate as the nail grows. “ I cannot stop scratching my left thumbnail at night, I am no longer sleeping as I used to”. The discomfort of the skin condition is about 8/10 for the patient as she is starting to reconsider social gatherings.

Medications

Allergies:

Allergic to certain detergents and acetone-based nail polish remover.

Past Medical History (PMH) Possibilities

  1. Systemic diseases (autoimmune, infectious, psychological, and renal diseases).
  2. Atopic dermatitis
  3. Chronic eczema
  4. Psoriasis
  5. Gland disease
  6. Tuberculosis
  7. Malnutrition and Sjogren syndrome

Objective Data

Vital signs: RR General

HEENT:

Diagnostics/Lab Tests and Results

  1. Thyroid studies
  2. Complete blood cell count
  • An erythrocyte sedimentation rate (to determine acute inflammation)
  1. Taking nail plate and subungual debris samples (to rule out onychomycosis).

Assessment

Differential Diagnosis (DDx):

  1. Onychoschizia
  2. Nail psoriasis
  3. Onychomycosis
  4. Onychorrhexis
  5. Trachyonychia

Primary Diagnoses

  1. Onychoschizia
NURS 6512: Week 4: Assessment of the Skin, Hair, and Nails Assignment References

Haneke, E. (2017). Nail psoriasis: clinical features, pathogenesis, differential diagnoses, and management. Psoriasis (Auckland, NZ), 7, 51. http://doi.org.10.2147/PTT.S126281

Lipner, S. R., & Scher, R. K. (2019). Onychomycosis: clinical overview and diagnosis. Journal of the American Academy of Dermatology, 80(4), 835-851. https://doi.org/10.1016/j.jaad.2018.03.062

Sparavigna, A., Tenconi, B., & La Penna, L. (2019). Efficacy and tolerability of a biomineral formulation for treatment of onychoschizia: a randomized trial. Clinical, Cosmetic and Investigational Dermatology, 12, 355. http://doi.org.10.2147/CCID.S187305