Skin, hair, nails Flashcards
Function of the skin
- protection
- prevention of penetration
- perception
- temperature regulation
- identification (uniqueness of each individual)
- communication (blushing, blanching)
- wound repair
- absorption and excretion (some wastes/by-products)
- production of vitamin D
Considerations for assessment of skin
- pressure ulcers
- severe dehydration
- acute injury or lacerations (burns or deep wounds)
- suspicious rashes indicating infection
- cyanosis
- temperature
Skin turgor
- pinch and pull- if able to bounce back= good skin turgor
- chest, back of hand
Subjective data for skin assessment: SAMPLE
- S= symptom assessment (OPQRSTUV)- location
- A= allergies
- M= medications
- P= past history (encompasses childhood, medical, surgical, family, social, environmental, mental health)
- L= last visit to health professional
- E= evaluation of functional assessment
Other subjective data for skin/hair/nails to collect
- personal history; family history of skin disease (allergies, hives, psoriasis, eczema)
- change in color/pigmentation: hypopigmentation= loss of pigmentation, hyperpigmentation= increase in color; is the color change generalized or localized?- generalized e.g. pallor, jaundice, cyanosis= systemic illness
- change in mole: growth, neoplasms, itching, tenderness, bleeding
- pruritis (itching): most common of skin symptoms, occurs with dry skin, aging, medication reaction, allergy, obstructive jaundice, uremia, lice infestation
- excessive dryness or moisture: seborrhoea- oily, xerosis- dry; seasonal or constant?
- bruising, itching, rash or lesions: consider posibility of abuse, frequent falls (dizziness of neurological/CV origin), frequent minor trauma (possibly an adverse effect of alcoholism or other substance use), determine migration pattern/evolution
- change in nails
- hair loss: alopecia (significant loss), hirsutism (shaggy/excessive hair)
- environmental or occupational hazards: unprotected sun exposure –> lesions
- medications: aspirin/antibiotics/barbiturates/some tonics= produce allergic skin eruption, sulphonamides/thiazide diuretics/oral hypoglycemic agents/tetracycline= increase sunlight sensitivity and produce burn response, antimalarials/antineoplastic agents/hormones/metals/tetracycline= hyperpigmentation
- self-care behaviors: what do you do to care for your skin/nails/hair? what cosmetics, soaps or chemicals do you use?
- nutritional status
Objective assessment of skin
- color
- temperature
- moisture and texture
- edema
- mobility and turgor
- vascularity: circulation, visible blood vessels
- lesions and wounds
Skin inspect and palpate: Color- expected findings
Evenness of general pigmentation color
Skin inspect and palpate: Color- unexpected findings
- pallor: acute high-stress states, exposure to cold, cig smoking, anemia (assess conjunctiva and nail beds), local arterial insufficiency, shock
- jaundice: rising amounts of bilirubin in blood, liver inflammation, hemolytic disease, post severe burn state or infections, carotenemia (ingestion of large carotene-rich foods), uremia
- cyanosis: tissues are not adequately perfused with oxygenated blood, chronic heart and lung disease, exposure to cold, anxiety
- erythema (redness): from excess blood, expected with fever, local inflammation and increased skin temperature, polycythemia (increased number of RBCs), alcoholic intake, blushing, CO poisioning, venous stasis
Skin inspect and palpate: Temperature
- assess with dorsal aspect of hand- skin thinner on back of hand than palms
- simultaneous comparison bilaterally
Skin inspect and palpate: Temperature- expected findings
skin should be warm, temperature should be equal bilaterally (indicates normal circulatory status)
Normal conditions when hypothermia occurs
- generalized coolness may be induced for surgery or high fever
- localized coolness is expected with an immobilized extremity e.g. limb in cast, intravenous infusion
Abnormal conditions when hypothermia occurs
- general hypothermia accompanies central circulatory problems e.g. shock
- localized hypothermia occurs in peripheral arterial insufficency and Raynaud’s disease
Normal conditions when hyperthermia occurs
- generalized hyperthermia occurs with an increased metabolic rate e.g. fever, after heavy exercise
- localized area feels hyperthermic with trauma, infection or sunburn
Abnormal conditions when hypertermia occurs
hyperthyroidism produces an increase in metabolic rate, causing warmth and moistness of skin
Skin inspect and palpate: Moisture, texture and thickness
use palmar surface of fingers and hand
Skin moisture: Perspiration vs Diaphoresis
- Perspiration: response to activity, anxiety or a warm environment, appears normally on the face, hands, axilla and skinfolds
- Diaphoresis: accompanies an increased metabolic rate e.g. fever, occurs with thyrotoxicosis and with stimulation of the nervous system with anxiety or pain
Skin inspect and palpate: Texture- expected findings
smoothness, firmness, evenness
Skin inspect and palpate: Texture- unexpected findings
- hyperthyroidism: skin feels smoother and softer like velvet
- hypothyroidism: skin feels rough, dry and flaky
Skin inspect and palpate: Thickness- expected findings
thickened areas normal on palms and soles (calluses- circumscribed over growth of epidermis and is an adaptation to excessive pressure from the friction of work and weight bearing)
Skin inspect and palpate: Thickness- unexpected findings
skin is very thin and shiny (atrophic) with arterial insufficiency
Skin inspect and palpate: Edema
- most evident in dependent parts of body (feet, ankles, and sacral areas), where the skin looks puffy and tight
- fluid accumulating in the intercellular spaces and is not normally present
- to check for edema: imprint your thumb firmly against the ankle malleolus or the tibia, normally the skin surface resumes its smoothness immediately, if your pressure leaves a dent in the skin- “pitting” edema is present, presence is graded on 4-point scale
4-point edema scale
- 1+: mild pitting, no indentation, no perceptible swelling of the leg
- 2+: moderate pitting, indentation subsides rapidly
- 3+: deep pitting, indentation remains for a short time, leg looks swollen
- 4+: very deep pitting, indentation lasts a long time, leg is very swollen
Skin turgor vs mobility
- mobility: skin’s ease of rising
- turgor: skin’s ability to return to place promptly
Skin inspect and palpate: Vascularity/bruising
- multiple contusions
- cherry angiomas: slightly raised bright red that commonly appear on the trunk, normally increase in size and number with aging and are not significant
- varicosities: any bruising (ecchymosis) should be consistent with expected trauma of life, normally no venous dilations or varicosities (swollen veins)
Skin lesion characteristics to assess
- color
- elevation
- pattern/shape (grouping or distinctness of each one)
- size (cm)
- location and distribution (is it generalized or localized?)
- any exudate: color, odor, amount
- tenderness, mobility, consistency
How to palpate skin lesions
- wear gloves
- roll nodule between the thumb and index finger to assess depth
- gently scrape a scale to see whether it comes off- note the nature of its base or whether it bleeds when the scale comes off
- note the surrounding skin temperature
Primary skin lesion
direct result of the disease process, lesion develops on previously unaltered skin
Secondary skin lesion
evolves from primary (may be caused by scratching, trauma, infection, healing process)
Skin inspect and palpate: Wounds
- location
- size
- color
- texture
- drainage
- margins
- surrounding skin
- stage or phase of healing
Inspecting hair
- color: comes from melanin production and may vary from pale blond to totally black, greying normally begins as early as the 3rd decade of life because of reduced melanin production in the follicles
- texture: fine or thick, should look shiny
- distribution: fine vellus hair coats the body, coarser terminal hairs grow at eyebrows, eyelashes and scalp, hirsutism: excess body hair
- hair loss
- hair shaft
- lesions: separate hair into sections and life it, observing the scalp, when the patient has a history of itching inspect the hair behind the ears and in the occipital area, all areas should be clean and free of any lesions or pest inhabitants, many people normally have seborrhea (dandruff)
Palpating hair
smoothness and security
Inspecting nails: Shape and contour (profile)- expected findings
- nail surface is slightly curved/flat (160 degrees or less), and the posterior and lateral folds are smooth and rounded
- nail edges are smooth, rounded and clean, suggesting adequate self-care
Inspecting nails: Shape and contour (profile)- unexpected findings
- chronic iron-deficiency anemia may present with “spoon” nails, a concave shape
- paronychia (red, swollen, tender inflammation of the nail folds) occurs with trauma or infection
- jagged nails, nail bitten to the quick, or truamatized nail folds from chronic nervous picking suggests nervous habits
- chronically dirty nails suggests poor self-care or chronic staining of some occupations
Inspecting nails: Color- expected findings
- translucent nail plate shows an even pink nail bed underneath
- white hairline linear markings
Inspecting nails: Color-unexpected findings
- brown linear streaks= melanoma
- leukonychia striata= trauma or picking at cuticle
Inspecting nails: Thickness-expected findings
uniform thickness
Inspecting nails: Consistency-expected findings
- nail surface is smooth and regular, not brittle or splitting
- nail is firmly adherent to the nail bed and the nail base is firm to palpation
Inspecting nails: Consistency-unexpected findings
- pits, transverse grooves or lines may indicate a nutrient deficiency or may accompany acute illness in which nail growth is disturbed
- nails are thickened and ridged with arterial insufficiency
- a spongy nail base accompanies clubbing
Palpating nails
tenderness, smoothness
Capillary refill
- apply direct pressure to nail surface
- nail will blanch
- normal response, colour returns in <2-3 sec
Developmental considerations for skin: Infants
- temperature regulation ineffective- skin cannot protect much against cold because it cannot contract and shiver and because the subcutaneous layer is inefficent
- pigment system inefficient at birth
- skin is thin, smooth and elastic and relatively more permeable than that of an adult, and so the infant is at greater risk for fluid loss
- birthmarks, various erythema states, cyanotic conditions, vernix (present at birth, thick cheesy substance made up of sebum and shed epithelial cells), lanugo (fine hair), physiologic jaundice (excess RBCs get destroyed), milia (tiny white elevated spots on skin, from sebum that holds water in skin), acrocyanosis (bluish color disappears with warming), mottling (lacy pattern of small reddish and pale areas)
Developmental considerations for hair: Infants
cradle cap: scaly patches on baby’s scalp, yellow, greasy, crusty, from overactive oil glands in scalp
Developmental considerations for skin: children
dryness, rashes, bruising
Developmental considerations for hair: children
lice, dry scalp
Developmental considerations for nails: children
brittle nails
Developmental considerations for skin: adolescents
acne, cutting, infected piercings, tattoos
Developmental considerations for hair: adolescents
brittle hair, lice
Developmental considerations for nails: adolescents
brittle nails or injuries to nails
Developmental considerations for skin: pregnant women
- PUPPPS (pruritic urticarial papules/ plaques of pregnancy): patch of itchy, hive-like bumps that form in stretch marks on your belly and spread to other parts of body when pregnant
- striae: fragile connective tissues- may develop in the skin of the abdomen, breasts or thighs
- linea nigra: increased pigmentation in midline of the abdomen
- melasma: brown patches on skin
Developmental considerations for hair: pregnant women
brittle or thicker due to hormonal changes
Developmental considerations for nails: pregnant women
brittle or stronger due to hormonal changes
Developmental considerations for skin: older adults
- itchiness
- dryness (sweat glands and sebaceous glands decrease in number and function, increases risk for heat stroke)
- tearing/shearing (from loss of collagen)
- bruising
- decreased turgor (wrinkling, underlying dermis thins and flatens)- even though not dehydrated
- skin has less elasticity in the older population, and you can also see some of the age spots or liver spots on patient’s forearm
Developmental considerations for hair: older adults
loss of hair, brittle hair (number of functioning melanocytes decreases)
Developmental considerations for nails: older adults
brittle nails, splitting, clubbing, longitudinal ridging (from trauma at the nail matrix)
Diaper rash
- occlusive diapers or infrequent changing may cause a rash
- possible allergy to certain detergent or to disposable wipes
Danger signs of pigmented lesions: ABCD
- A: asymmetry- not regularly round or oval, two halves of lesion do not look same
- B: border irregularity- notching, scaloping, ragged edges or poorly defined margins
- C: color variation- areas of brown, tan, black, blue, red, white or combo
- D: diameter > 6 mm
Benign vs malignant moles
- Benign moles: symmetrical, borders are even, one shade, small than 1/4 inch
- Malignant moles: asymmetrical, orders are uneven, two or more shades, larger than 1/4 inch
Skin self-examination
advise anyone with moles or birthmarks to perform periodic skin self-examinations
Common shapes and configuration of skin lesions
- annular
- confluent
- discrete
- grouped
- gyrate
- target (iris)
- linear
- polycyclic
- zosteriform
Configuration of skin lesions: Annular
- circular lesions that begin in centre and spread to periphery
- e.g. tinea corporis (ringworm), tinea versicolor, pituriasis rosea
Configuration of skin lesions: Grouped
- clusters of lesions
- e.g. vesicles of contact dermatitis
Configuration of skin lesions: Discrete
- distinct, individual lesions that remain separate
- e.g. molluscum
Configuration of skin lesions: Confluent
- lesions that run together
- e.g. urticaria (hives)
Configuration of skin lesions: Zosteriform
- lesions form a linear arrangement along a nerve route
- e.g. herpes zoster
Configuration of skin lesions: Target (iris)
- lesions that resemble iris of eye; concentric rings of color in the lesions
- e.g. erythema multiforme
Primary skin lesions
- macule (patch)
- papule (plaque)
- nodule (tumor)
- wheal (uricaria/hives)
- vesicle (blister)
- cyst
- pustule
- bulla
Primary skin lesion: Nodule
- solid, elevated, hard or soft lesion
- > 1 cm diameter
- may extend deeper into dermis than papule
- e.g. xanthoma, fibroma, intradermal nevi
Primary skin lesion: Wheal
- superifical, raised, transient, and erythematous lesion; slightly irregular shape because of edema (fluid held diffusely in tissues)
- e.g. mosquito bite, allergic reaction, dermographism
Primary skin lesion: Pustule
- cavity filled with turbid fluid (pus); circumscribed and elevated
- e.g. impetigo, acne
Primary skin lesion: Macule
- solely a colour change; flat and circumscribed, <1 cm diameter
- e.g. freckle, flat nevi, hypopigmentation, petechiae, measles, scarlet fever
Primary skin lesion: Papule
- solid, elevated and circumscribed, <1cm diameter, caused by superficial thickening in the epidermis
- e.g. elevated nevus (mole), lichen planus, molluscum, wart (veruca)
Primary skin lesion: Cyst
- encapsulated fluid- filled cavity in dermis or subcutaneous layer, tensely elevating skin
- e.g. sebaceous cyst, trichilemmal cyst (wen)
Primary skin lesion: Vesicle
- elevated cavity containing free clear fluid, up to 1 cm, clear serum flows if wall is ruptured
- e.g. herpes simplex, early varicella (chicken pox), herpes zoster (shingles), contact derm
Primary skin lesion: Bulla
- usually single-chambered (uni locular), superficial in epidermis, >1cm diameter thin-walled, so ruptures easily
- e.g. friction blister, pemphigus, burns, contact derm
Secondary skin lesions: Debris on skin surface
- crust
- scale
Secondary skin lesions: Break in continuity of surface
- fissure
- erosion
- ulcer
- scar
- atrophic scar
- lichenification
- keloid
Secondary skin lesions: Fissure
- linear crack with abrupt edges, extending into dermis, dry or moist
- e.g. cheiolsis (at corners of mouth as a result of excess moisture)
Secondary skin lesions: Erosion
scooped out but shallow depression, superficial, epidermis lost, moist but no bleeding, healing without scar because erosion does not extend into dermis
Secondary skin lesions: Excoriation
- self-inflected abrasion, superficial, sometimes crusted, scratches from intense itching
- e.g. lesions caused by scratching of insect bites, scabies, dermatitis, varicella
Secondary skin lesions: Scar
connective tissue (collagen) that replace normal tissue after a skin lesion is repaired; a permanent fibrotic change
Secondary skin lesions: Atrophic scar
depression of skin level as a result of loss of tissue; a thinning of epidermis
Secondary skin lesions: Lichenification
thickening of skin with production of tightly packed sets of papules, caused by prolonged intense scratching
Secondary skin lesions: Ulcer
- depper depression extending into dermis, irregular shaped; may bleed, leaves scar when heals
- e.g. stasis ulcer, pressure injury, chancre
Secondary skin lesions: Keloid
hypertorphic scar; elevation of the resulting skin level by excess scar tissue, which is invasive beyond site of original injury; may increase long after healing occurs; looks smooth rubbery, “clawlike”, higher incidence among POC
Secondary skin lesions: Crust
- thickened, dried-out exudate left when vesicles or pustules burst or dry up
- color can be red-brown, honeylike, or yelllow depending on fluid’s ingredients (blood, serum, pus)
- e.g. impetigo (dry, honey-colored), weeping eczematous dermatitis, scab following abrasion
Secondary skin lesions: Scale
- compact, desiccated flakes of skin, dry or greasy; silvery or white, from shedding of dead excess keratin cells
- e.g. lesions after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichtyosis (large, adherent laminated), dry skin
