Health Assessment: Hair, Skin, and Nails

What is the largest organ of the body

The skin

What does the structure/ function of the skin do?

• Guards the body from environmental stress 

• Adapts to environmental influences

What are the 2 layers of the skin

Epidermis and Dermis

What is beneath the 2 layers of the skin?

•  subcutaneous layer of adipose tissue

What are the functions of the skin?

Communication/ Protection

• Prevents penetration, Perception, Temp. Regulation, Identification, wound repair (cools us down), Absorption/ Excretion, Production of Vitamin D

Subjective Data: Health History Questions

• Past history, Change in pigmentation, change in mole (size color, Excessive dryness or moisture

• Pruritus (itching), Excessive bruising, Rash or lesion, Medications, Hair loss, Change in nails

• Environmental or occupational hazards (where they work or live)

• Patient-Centered care: Do you perform a skin-self examination?

Objective Data: The Physical Exam

• Preparation: Skin characteristics

• Equipment needed: Strong direct lightening, small centimeter ruler, penlight, gloves

What are special procedures done on the Physical exam?

• Wood’s light: UV light filtered through a special glass; detects fluorescing lesions; Lesions with blue-green fluorescence indicates fungal infection

• Light magnifier

What is Capillary Refill (peripheral Circulation):

With the index finer or middle fingertip at heart level, depress the nail edge at least 5 seconds to blanch and then release, noting the return of color

What is does normal capillary refill show?

• Normally color return is instant or at least within a few seconds (1-2) in a cold environment

What does abnormal capillary refill do?

• Cyanotic nail beds or sluggish color return >3 seconds indicated clinical deadline (cardiovascular or respiratory failure, septic shock)

Objective Data: They Physical Exam

Complete Physical Examination:

Learn to consciously assess or attend to surface skin characteristics

• Don’t ignore- skin’s information about circulation, nutritional status, and signs of systemic diseases and topical data (things they have been exposed to)

• Know the person’s normal/baseline skin coloring and self-monitoring practices

• Separate intertriginous areas (skinfolds) and inspect them (always remove socks)

What does regional examination do?

Individual seeks care because of changes

• Assessment- Focused on skin alone

Inspection and Palpation

Temperature:

• Hypomeia: (above-hot)

• Hypermeia: (below-cool)

Moisture: 

• Diaphoresis (sweating profusely)

• Dehydration (check skin turgor)

Texture and Thickness

Color:

• General pigmentation:

• Freckles, mole (nevus), birthmarks

• Widespread color change

• Pallor, Erythema, Cyanosis, Jaundice

Skin Color:

• Pallor:

• When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen) which is mostly WHITE

Skin Color: Erythema

• Intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries

Skin Color: Cyanosis

• Bluish mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood

Skin Color: Jaundice

•  A yellowish skin color indicates rising amounts of bilirubin in the blood

Inspection and Palpation

Edema: 

• Unilateral vs. Bilateral

• Pitting Edema

• Anasarca

Mobility and Turgor:

• Assess skin elasticity

• Poor turgor (INFANTS)

• Scleroderma: autoimmune disorder-changes skin like stone

Inspection and Palpation: Lesions

• Traumatic or pathologic changes

• Note the color

• Elevation: flat, raised, or pedunculated

• Pattern or shape

• Size: In centimeters (sm)

• Location and distribution on the body: generalized or localized 

Common Skin Lesions:

• Primary Contact Dermatitis:

• A rash; one area- where it was touched

Common Skin Lesions:

Allergic Drug Reaction and Tinea Versicolor

Common Skin Lesions: Tinea Corporis (Ringworm of the BODY):

• fungal infection; scalp or on the body

Common Skin Lesions: Tinea Pedis: (Ringworm of the FOOT)

• athletes foot

Common Skin Lesions: Psoriasis

• Systemic condition in the folds

Common Skin Lesions: Herpes Zoster (Shingles):

• Extremely painful- runs along pattern

Common Skin Lesion: Erythema Migrants of Lyme Disease:

• Localized area of erythema

Common Skin Lesions: Labial Herpes Simplex (Cold Sores):

• Usually apparel on the mouth

Lesions: Abnormal characteristics of pigmented lesions are summarized by

ABCDEF

ABCDEF: What does A stand for?

• Asymmetry: Not regularly round or oval; two halves of lesion don’t look the same

ABCDEF: What does B stand for?

• Border Irregularly: Notching, scallpoing, ragged edges, poorly defined margin; Important for pressure ulcers

ABCDEF: What does C stand for?

• Color Variation: Areas of brown, tan, black, blue, red, white, or combination

ABCDEF: What does D stand for?

• Diameter: Greater than 6 mm (size of pencil eraser)

ABCDEF: What does E stand for?

• E: Elevation or Evolution

ABCDEF: What does F stand for?

• Funny looking: “ugly duckling” sign- the suspicious lesion stands out as looking different compared with its neighboring nevi

Common Shapes and Configurations of Lesions:

• Annular or Circular:

• Beings in center and spreads to periphery

Common Shapes and Configurations of Lesions: Confluent:

Lesions run together

Common Shapes and Configurations of Lesions: Discrete

• distinct and separate

Common Shapes and Configurations of Lesions: Grouped

•  Cluster of lesions

Common Shapes and Configurations of Lesions: Gryate

•  twisted, coiled, or snakelike

Common Shapes and Configurations of Lesions: Target or iris

• resembles iris of eyes, concentric rings

Common Shapes and Configurations of Lesions: Linear

• Scratch, streak, line (scabies), or stripe

Common Shapes and Configurations of Lesions: Polycytic

• Annular lesion grow together

Common Shapes and Configurations of Lesions: Zosteriform

•  Linear arrangement following a unilateral nerve route

Primary Lesions

Macule:

• Flat, color change; Ex: freckles

Primary Lesions: Papule

• Solid, less than 1 cm; Ex: moles

Primary lesions: Patch

•  Macules that are larger than 1 cm; Ex: Measles

Primary lesions: Plaque

• form surface elevation wider than 1 cm- Disk-shaped lesion; Ex: sclerosis

Primary lesions: Nodule

• Solid, elevated, hard or soft, larger than 1 cm; xanthoma

Primary lesions: Tumor

•  deeper into dermis, may be benign or malignant; Lipoma, hemangioma

Primary lesions: Wheal

• Superficial, raised, irregular shape; mosquito bite/ allergic reaction

Primary lesions: Urticaria (Hives)

• Whereas coalesce to form extensive reaction

Primary lesions: Vesicle

• Elevated cavity containing free fluid (blister); herpes simplex, chicken pox

Primary lesions: Bulla

•  larger than 1 cm, superficial in epidermis; Ex: friction blister, burns, contact dermatitis

Primary lesions: Cyst

• Encapsulated fluid filled cavity in dermis; Ex: sebaceous cyst 

Primary lesions: Pustule

• Turbid fluid (pus)’ Ex: Impetigo acne

Secondary Skin Lesion

• Debris on skin surface: Crust

• Thickened dried out exudate

Secondary Skin Lesion

• Debris on skin surface: Scale

•  Compact flakes on desiccated skin from shedding of dead excess keratin cells

Secondary Skin Lesion: Break in continuity of skin surface

Fissure:

•  Linear crack with abrupt edges extending into dermis

Secondary Skin Lesion: Break in continuity of skin surface: Erosin

• Scooped Out But Shallow Depression

Secondary Skin Lesion: Break in continuity of skin surface: Ulcer

• Deeper depression extending into dermis with irregular shape, may bleed, leaves scare

Secondary Skin Lesion: Break in continuity of skin surface: Excoriation

•  Self-inflicted abrasion that is superficial

Secondary Skin Lesion: Break in continuity of skin surface: Scar

•  Permanent fibrotic change after healing

Secondary Skin Lesion: Break in continuity of skin surface: Atrophic Scar

• Resulting skin level is depressed with loss of tissue and thinning

Secondary Skin Lesion: Break in continuity of skin surface: Lichenification

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

Secondary Skin Lesion: Break in continuity of skin surface: Keloid

• Benign excess of scar tissue beyond original injury

Pressure Injuries (Pressure Ulcer, Decubitus Ulcer)

• Pressure Injuries (PIs) appear on the skin over a bony prominence when circulation is impaired

• Immobilization impedes delivery of blood/oxygen/nutrients to skin and venous drainage. This results in ischemia and cell death

• Risk factors:

• Impaired immobility, thin fragile skin of aging, decreased sensory perception, impaired LOC, moisture from urine/ stool incontinence, shearing injury, poor nutrition and infection

What are common sites for pressure injuries?

• Back- Sacrum, heel, elbow, scapula, vertebra

• Side: Ankle, knee, hip, run, shoulder

What are the Pressure Injury Stages?

1. Stage 1: Non-Blanchable erythema (stays red)

2. Stage 2: Partial-thickness skin loss

3. Stage 3: Full-thickness skin loss (stay into dermis)

4. Stage 4: Full- thickness skin/tissue loss (ligaments)

5. Deep Tissue Pressure Injury (DTPI)

6. PI Caused by Medical Device

Vascular Lesions

Hemangiomas:

• Caused by a benign proliferation of blood vessels in the dermis

• Port-Wine Stain (Nevus Flammeus)

• Strawberry Mark (Immature Hemangioma)

• Cavernous Hemangioma (Mature)

Vascular Lesions: Telangiectasia

• Caused by vascular dilation

• Telangiectasia

• Spider or Star Angioma

• Venous Lake

Vascular Lesions: Purpuric Lesions:

• caused by blood flowing out of breaks in the vessels. RBCs and blood pigments are deposited in the tissue (extravascular). Difficult to see in dark-skinned people

• Petechiae

• Ecchymosis: Bruising that came from the inside out 

• Purpura

• Contusion (Bruise): Only one that is caused by Blunt Trauma

Malignant Skin Lesions

• Basal Cell Carcinoma (flat then raised)

• Squamous cell Carcinoma 

• Malignant Melanoma (tanned, black)

Developmental Competence: Infants and Children

• Temperature regulation is not effective

Developmental Competence: Infants and Children- Normal Findings

• Mongolian Spot, Cafe au lait spot (birthmark), Physiologic jaundice, Milia, port Wine stain

What is the most common skin problem in adolescents?

Acne

• Severe acne includes papules, pustules, and nodules

What is turgor

Poor turgor or “tenting” indicates dehydration, especially when combined with delayed capillary refill and tachypnea; also occurs with malnutrition

Where do you test for turgor and skin mobility in infants?

Over the abdomen

Common Skin Lesions in Children

Diaper dermatitis, Intertrigo (candidiasis), Impetigo, Atpoic dermatitis (eczema), Measles (rubeola), German measles (rubella), Chickenpox (varicella)

Developmental Competence: Pregnant Women

• Sweat and sebaceous glands increase secretion

• Expected skin color changes due to increased hormone levels

Developmental Competence: Pregnant Women- Normal Findings:

• Striae “stretch marks”, Linea nigra, Chloasma (butterfly across face), Vascular Spiders (Spider angioma)- Varicose veins

Developmental Aging Adult:

• Loss of elastin, collagen, subcutaneous fat, and reduction of muscle tone

• Epidermis thins and flattens > wrinkling occur

• Aging skin increase risk for pressure ulcers

Developmental: Aging Adult- Normal Findings

• Senile lentigines (liver spots), Seborrheic Keratosis, Actinic keratosis

Cultural 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 

What is hair?

Threads of Keratin

• Shaft, Root, Bulb Matrix, Hair follicle

What are the two types of hair?

• Vellus hair and Terminal Hair

Inspection of Hair: 

Color

• Hair color comes from melanin production

• Vary from pale blond to total black

• Graying begins as early as the 30s b/c of reduced melanin production in the follicles

• Genetic factors affect the onset of graying

Inspection of Hair: Texture

• Note dull, coarse, or brittle scalp of hair

• Tinea Capitis: Gray, scaly, well-defined areas with broken hairs (baby's- “milk spots”)

• Loss of eyebrows and scalp hair (expected) with chemotherapy or hypothyroidism

Palpation of the Hair:

Distribution:

 Fine vellus hair coats the body

• Coarser terminal hair grows at eyebrows, eyelashes, and scalp 

• Puberty- coarse curly hairs

• Absent or sparse genital hair suggests endocrine abnormalities

• Hirsutism

Palpation of the Hair: Lesions

Separate the hair into sections and lift to observe the scalp

• Should be clean and free of any lesions or prest inhabitants

• Lice- head or pubic areas

Abnormal Hair Conditions

• AIDS- Related Kaposi sarcoma: patch stage

• Toxic alopecia, Traction alopecia, hirsutism, Furuncle and abscess

• Tinea Capitis (scalp ringworm), Seborrheic Dermatitis (cradle cap), Pediculosis Capitis (head lice), Folliculitis Barbae (“razor bumps”)

What are Nails?

Hard plates of keratin

• Clear with longitudinal ridges

• Pink color

Inspection of the Nails: 

• Shape and Contour

• The profile sign

• Clubbing of nails- occurs with pulmonary diseases, lung cancer, and congenital cyanotic heart disease

• Consistency, Color

Abnormal Conditions of the Nails:

• Scabies Paronychia, Beau Line, Splinter Hemorrhages, Onychomycosis, Late Clubbing, Pitting, Habit-tic dystrophy

Health promotion and Teaching:

 Educate on the dangers of excessive UV exposure from indoor tanning equipment

• Sun lamps, beds, booths

• Long- term tanning can lead to something more frightening and deadly

• Increased risk of melanoma

• Increased risk of non-melanoma skin CA (squamous and basil cell carcinoma)

• “Tan Tax”- 10% tax on use of YV indoor tanning 

• Teach Skin self-examination