Health Assessment 06

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Chapter 13

Skin, Hair, and Nails

Structure: Skin

Think of skin as body’s largest organ system.

Covers 20 square feet of surface area in adults

Skin is the sentry that guards body.

Skin has two layers

Epidermis: outer highly differentiated layer

Basal cell layer forms new skin cells.

Outer horny cell layer of dead keratinized cells

Dermis: inner supportive layer

Connective tissue or collagen

Elastic tissue

Beneath these layers is a subcutaneous layer of adipose tissue.

Stores fat for energy, provides insulation for temperature control and aids in protection

Layers of Skin

Derived from three sources:

Melanin—brown pigment

Carotene—yellow-orange pigment

Red purple tones in the underlying vascular bed

All individuals have varying amounts (red, yellow, and brown).

With the relative proportion affecting prevailing color

Also modified by thickness of skin and presence of edema

Skin Color

Hair, Sebaceous Glands and Sweat Glands

Structures formed by tubular invagination of epidermis down into underlying dermis

Hair

Sebaceous glands

Sweat glands: important for fluid balance and thermoregulation

Eccrine glands

Apocrine glands

Hair

Threads of keratin—hair shaft and bulb matrix

Types of hair—vellus and terminal

Follicle—cyclical with active and resting phases

Sebaceous glands

Sebum—secreted lipid substance through hair follicles

Lubricate skin and form emulsion

Sweat glands

Eccrine produce sweat.

Apocrine produce milky secretion and open into hair follicles.

Nails

Hard plates of keratin on dorsal edges of fingers and toes

Hair, Sebaceous Glands, Sweat Glands and Nails

Structure of Nails

Skin Function

Skin is waterproof, protective, and adaptive

Protection from environment

Prevents penetration

Perception

Temperature regulation

Identification

Communication

Wound repair

Absorption and excretion

Production of vitamin D

Developmental Competence: Infants, Children, and Adolescents

Newborn infants

Lanugo: fine downy hair of newborn infant

Vernix caseosa: thick, cheesy substance

Sebum: holding water in the skin producing milia

Children

Epidermis thickens, darkens, and becomes lubricated.

Hair growth accelerates.

Adolescents

Secretions from apocrine sweat glands increase.

Subcutaneous fat deposits increase.

Secondary sex characteristics

Developmental Competence: The Pregnant Woman

Increase in metabolism leads to increase secretion of sweat and sebaceous glands to dissipate heat.

Expected skin color changes due to increased hormone levels.

Fat deposits are laid down as maternal reserves for nursing baby.

Developmental Competence: The Aging Adult

Elasticity

Loses elasticity; skinfolds and sags

Sweat and sebaceous glands

Decrease in number and function, leaving skin dry

Senile purpura

Discoloration due to increasing capillary fragility

Skin breakdown due to multiple factors

Cell replacement is slower and wound healing is delayed.

Hair matrix

Functioning melanocytes decrease, leading to gray fine hair

Culture and Genetics

Genetic attributes of dark-skinned individuals afford protection against skin cancer due to melanin.

Increased likelihood of skin cancer in whites than in black and Hispanic populations

Succession of genetic mutations leading to increased chromosome sensitivity to sun damage

Most important environmental risk factor for skin cancer is exposure to ultraviolet (UV) radiation both from sun and indoor tanning sources.

Increased risk for melanoma r/t increased number of sunburns during one’s lifetime.

Certain skin presentations are associated with different ethnic groups.

Subjective Data Health History Questions

Past history of skin disease, allergies, hives, psoriasis, or eczema?

Change in pigmentation?

Change in mole (size or color)?

Excessive dryness or moisture?

Pruritus?

Excessive bruising?

Rash or lesions?

Medications?

Hair loss?

Change in nails?

Environmental or occupational hazards?

Patient-centered care?

Additional History Questions for Infants and Children

Does child have any birthmarks?

Any change in skin color as a newborn?

Does child have any rash or sores?

Does child have diaper rash?

Does child have any burns or bruises?

Has child been exposed to contagious or communicable disease?

Does child have habits such as nail biting or twisting hair?

What steps are taken to protect child from sun exposure?

Additional Health History Questions

Adolescents

Skin problems such as pimples, blackheads?

Aging adults

What changes have you noticed in your skin in past few years?

Any delay in wound healing?

Any change in feet: toenails, bunions, wearing shoes?

Falling: bruises, trauma?

History of diabetes or peripheral vascular disease?

Objective Data

Preparation

Consciously attend to skin characteristics; the danger is one of omission.

Equipment needed

Strong direct lighting, gloves, penlight, and small centimeter ruler

For special procedures

Wood’s light

Magnifying glass

Materials for laboratory tests: potassium hydroxide (KOH) and glass slide

Physical Examination

Complete physical examination

Skin assessment integrated throughout examination

Scrutinize the outer skin surface first before you concentrate on underlying structures.

Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly

Always inspect feet, toenails, and between toes.

Regional physical examination

Individuals may seek health care for skin problems and assessment focused on skin alone.

Assess skin as one entity; getting overall impression helps reveal distribution patterns.

Inspection and Palpation: Skin (1 of 3)

Color

General pigmentation, freckles, moles, birthmarks

Widespread color change

Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow).

Note if color change transient or due to pathology.

Temperature

Use backs of hands to palpate person.

Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status.

Hands and feet may be slightly cooler in a cool environment.

Hypothermia

Hyperthermia

Inspection and Palpation: Skin (2 of 3)

Moisture

Diaphoresis

Dehydration

Texture

Normal skin feels smooth and firm with even surface.

Thickness

Observe for thickened areas (callus formation).

Edema

Assess for fluid accumulation in the interstitial space

Mobility and turgor

Assess skin elasticity

Vascularity or bruising

Assess for presence of tattoos and/or variations

Lesions: if any are present, note the following:

Color

Elevation

Pattern or shape

Size

Location and distribution on body

Any exudate: note color and odor

Use a Wood’s light (ultraviolet light filtered through special glass) to detect fluorescing lesions.

Inspection and Palpation: Skin (3 of 3)

Inspection and Palpation: Hair

Color

Due to melanin production

Texture

Characteristics range from fine to thick to curly to straight and may be affected by use of hair care products.

Distribution

Tanner staging identifies gender patterns of hair distribution.

Lesions

Identification by looking at scalp and dividing hair into sections

Inspection and Palpation: Nails

Shape and contour

Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees

Consistency

Observe for smooth, regular, not brittle or splitting, uniform nail thickness.

Color

Translucent nail plate to pink nail bed below

Note ethnic variations

Capillary refill

Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation.

Profile Sign: Clubbing

ABCDEF Skin Assessment

Promoting health and self-care

Teach skin self-examination using ABCDEF rule to detect suspicious lesions

A: asymmetry

B: border irregularity

C: color variations

D: diameter greater than 6 mm

E: elevation or evolution

F: funny looking—“ugly duckling” —different from others

Skin color—general pigmentation

Mongolian spot

Café-au-lait spot

Skin color change

Harlequin color change

Erythema toxicum

Temporary cyanotic conditions

Acrocyanosis

Cutis marmorata

Physiologic jaundice

Carotenemia

Moisture, texture, thickness, mobility and turgor

Vascularity or bruising—nevus simplex

Hair and nails—lanugo and presence of cyanosis in newborn

Developmental Competence: Infant Skin Presentations

Adolescent

Acne

Open and closed comedones

Pregnancy

Striae

Linea nigra

Chloasma

Vascular spiders

Developmental Competence: Life-Cycle Presentations (1 of 2)

Aging

Skin color and presentations

Senile lentigines

Keratoses

Moisture

Xerosis

Texture

Skin tags or acrochordons

Thickness

Thin parchment

Decreased mobility and turgor

Decreased hair growth, nail growth, and brittle nails

Developmental Competence: Life-Cycle Presentations (2 of 2)

Be aware of normal variations for the following variables:

Pallor

Cyanosis

Erythema

Jaundice

Brown-tan

Detecting Color Changes in Light and Dark Skin

Shapes and Configurations of Lesions (1 of 2)

Annular or circular

Begins in center and spreads to periphery

Confluent

Lesions run together

Discrete

Distinct and separate

Grouped

Cluster of lesions

Gyrate

Twisted, coiled, or snakelike

Shapes and Configurations of Lesions (2 of 2)

Target or iris

Resembles iris of eyes, concentric rings

Linear

Scratch, streak, line, or stripe

Polycyclic

Annular lesions grow together.

Zosteriform

Linear arrangement following a unilateral nerve route

Annular or Circular

Begins in center and spreads to periphery

Confluent

Lesions run together

Discrete

Distinct and separate

Grouped

Cluster of lesions

Gyrate

Twisted, coiled, or snakelike

Target or Iris

Resembles iris of eyes, concentric rings

Linear

Scratch, streak, line or stripe

Polycyclic

Annular lesions grow together.

Zosteriform

Linear arrangement following a unilateral nerve route

Macules

Solely a color change, flat and circumscribed, less than 1 cm

Papules

Felt and caused by superficial thickening of the epidermis

Patches

Macules that are larger than 1 cm

Plaques

Papules coalescing to form surface elevation wider than 1 cm

Nodules

Solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule

Wheals

Superficial, raised, transient and erythematous, irregular in shape due to edema

Primary Skin Lesions (1 of 2)

Tumors

Larger in diameter, firm or soft, deeper into dermis, may be benign or malignant,

Urticaria (hives)

Wheals coalesce to form extensive pruritic reaction.

Vesicles

Elevated cavity containing fluid up to 1 cm (blister)

Cysts

Encapsulated fluid filled cavity

Bullas

Larger than 1 cm diameter, usually single chamber, superficial in dermis and ruptures easily

Pustules

Pus in cavity that is circumscribed and elevated.

Primary Skin Lesions (2 of 2)

Macule and Patch

Papule and Plaque

Nodule and Tumor

Wheal and Urticaria/Hives

Vesicle and Bulla

Cyst

Pustule

Debris on skin surfaces

Crust—Thickened dried out exudate

Scale—Compact flakes of desiccated skin from shedding of dead excess keratin cells

Break in continuity of skin surface

Fissures—Linear crack with abrupt edges extending into dermis

Erosions—Scooped out but shallow depression

Ulcers—Deeper depression extending into dermis with irregular shape, may bleed, leaves scar

Secondary Skin Lesions (1 of 2)

Break in continuity of skin surface

Excoriations—Self-inflicted abrasion that is superficial

Scars—Permanent fibrotic change after healing

Atrophic scars—Resulting skin level is depressed with loss of tissue and thinning

Lichenifications—Prolonged intense scratching leads to thickened skin producing tightly packed set of papules

Keloids—Benign excess of scar tissue beyond original injury

Secondary Skin Lesions (2 of 2)

Crust

Scale

Fissure

Erosion

Ulcer

Excoriation

Scar

Atrophic Scar

Lichenification

Keloid

Stages

Stage I: Non-blanchable erythema

Stage II: Partial-thickness skin loss

Stage III: Full-thickness skin loss

Stage IV: Full-thickness skin/tissue loss

Deep tissue pressure injury (DTPI)

PI caused by medical device

Pressure Injuries (PI) Pressure Ulcer, Decubitus Ulcer

Hemangiomas

Port-wine stain (nevus flammeus)

Strawberry mark (immature hemangioma)

Cavernous hemangioma (mature)

Telangiectases

Spider or star angioma

Venous lake

Vascular Lesions (1 of 2)

Purpuric lesions

Petechiae

Ecchymosis

Purpura

Lesions caused by trauma or abuse:

Pattern injury

Hematoma

Contusion (bruise)

Vascular Lesions (2 of 2)

Common Skin Lesions in Children

Diaper dermatitis

Intertrigo (candidiasis)

Impetigo

Atopic dermatitis (eczema)

Measles (rubeola)

German measles (rubella)

Chickenpox (varicella)

Primary contact dermatitis

Allergic drug reaction

Tinea corporis (ringworm of the body)

Tinea pedis (ringworm of the foot)—Athlete's foot

Labial herpes simplex (cold sores)

Tinea versicolor

Herpes zoster (shingles)

Erythema migrans of lyme disease

Psoriasis

Common Skin Lesions

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Malignant Skin Lesions

AIDS-related Kaposi sarcoma: patch stage

Toxic alopecia

Tinea capitis (scalp ringworm)

Traction alopecia

Seborrheic dermatitis (cradle cap)

Pediculosis capitis (head lice)

Folliculitis barbae (“razor bumps”)

Hirsutism

Furuncle and abscess

Abnormal Hair Conditions

Scabies

Paronychia

Beau line

Splinter hemorrhages

Onychomycosis

Late clubbing

Pitting

Habit-tic dystrophy

Abnormal Conditions of the Nails

Summary Checklist: Skin, Hair, and Nails

Inspection of the skin, hair, and nails

Color and pigmentation

Texture and distribution

Shape, contour, and consistency

Palpation of the skin, hair, and nails

Temperature and texture

Edema, mobility, and turgor

Note presence of lesions

Shape, configuration, and distribution

Teach self-examination

Health promotion