Skin, hair and nails health assessment

Pediculosis

head lice, patient is itchy, has red scalp happens from person to person

Striae

commonly seen in obesity or pregnancy or areas of rapid growth. not harmful. Generally, fade or appear more slivery or pink colored over time.

Cyanosis in lighter skin

grayish-blue tone. best seen in nailbeds, earlobes, lips, mucous membranes, palms and soles of feets

Cyanosis in darker skin

Ashen grey color. Best seen in conjunctiva of eyes, oral mucosa (ASSESS HERE, best seen here) and nailbeds

Ecchymosis in lighter skin

bruise is a dark red, purple, yellow or green color. Depends on age of bruise

Ecchymosis in darker skin

bruise is a deeper bluish/black tone. More difficult to see unless it occurs in area of light pigmentation

Erythema in lighter skin

Reddish tone. Increased skin temperature, and tenderness, secondary to inflammation

Erythema on darker skin

Deeper brown or purple skin tone. Increased skin temperature, secondary to inflammation

Jaundice on lighter skin

Yellowish color due to excess bilirubin. best seen in skin, sclera of eyes, fingernails, palms and oral mucosa

Jaundice on darker skin

Yellowish-green color, best seen in sclera of eye, palms and soles of feet

Petechiae on lighter skin

Lesions appear as small reddish/purple pinpoint areas.

What causes Jaundice

possible liver or gallbladder disease or medication side effects

What causes Petechiae

broken capillaries, they are flat not itchy, not a rash. Various causes some benign, some serious. These are tiny flat reddish-purplish nonblanchable spots on the skin that are 0.5 cm in diameter: appear as tiny red spot pin spots, pinpoint to pinhead in size

Petechiae on Darker skin

More difficult to see. May be more evident in buccal mucosa of the mouth or sclera of eye

Rashes on lighter skin

visible and palpable

Rashes on darker skin

Not easily seen but may be palpable

Urticaria (hives/wheals)

Usually due to allergy to something, usually acute can be treated with antihistamines. May be difficult to see in darker skin but can be palpated as the wheals are raised. Acute hives may be a sign of Type I allergic reaction anaphylaxis and can be followed by wheezing and respiratory arrest

Nevi (moles)

usually above the wrist or on sun exposed areas. Typically, less than 5 mm, uniform color, border should be smooth. They are non-blanchable

When is a nevi (moles) concerning

when it is greater than 6mm, itchy, blanchable, color is uneven/variegated, getting bigger and if it has an abnormal border

Pressure injury stage 1

intact skin with non blanchable redness, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue (lack of perfusion). May be difficult to detect in individuals with dark skin tones.

Pressure injury stage 2

Partial thickness loss of dermis. Presents as a shiny or dry open ulcer with pink wound bed without slough or bruising. May also present as an intact or open/ruptured serum filled blister.

Pressure injury stage 3

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present; wound may include undermining and tunneling. Depth depends on location.

Pressure injury stage 4

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present within the wound bed. Undermining and tunneling often present. Depth depends on location

Kennedy Terminal Ulcer (KTU; pressure injury)

Sudden

grow rapidly

usually appear in sacral region

look like pear/butterfly (irregular shaped)

Associated with terminally ill patients

Pressure injury: unstageable

Full thickness tissue loss in which base of ulcer is covered by slough (yellow, tan, gray-green or brown). True depth of the wound cannot be determined until the slough and/or eschar is/are removed to expose the base of the wound.

Deep tissue pressure injury (DTI)

localized area of dicolored (purple/maroon) intact skin or blood filled blister caused by underlying soft tissue damage resulting from pressure or shear. May be difficult to detect among individuals with dark skin tones. May include a blister over a dark wound bed. Wound may become covered with eschar

Alopecia

autoimmune condition, sometimes grows back sometimes it doesn’t. Most common in men

Hirsutism

hair on females in spots where it usually does not grow.

PCOS: males hormones are present (testerone) in females

females use lasers/different ways to get rid of this hair

Congenital Dermal Melanocyte (Malgomian spots)

babies with high levels of melanin (darker babies not caucasions). Looks like a bruise. Very important to document so no one thinks its an abusive mark from parents. Usually go away, found often on buttocks/backside

Nervous simplex (stork bite)

Big patch on neck, sometimes on eye (completely normal). Usually goes away, but if it stays (no worries not harmful)

Nodule

solid, elevated firm, lump that is deeper in the dermis and usually larger than a papule. Is 1-2 cm in diameter

Pallor in light skin

pale skin color that may appear white

pallor in dark skin

skin tone appears lighter than normal; light-skinned African American may have yellowish brown skin. Dark-skinned African Americans may appear ashen; specifically evident is a loss of the underlying healthy red tones of the skin. Look at conjunctiva to see pale color to confirm

Scar on light skin

narrow scar line, this is a thin fibrous tissue that replaces normal skin

scar on dark skin

frequently has keloid development resulting in a thickened, raised scar

Macules

these are freckles which are small, flat, hyperpigmented that may appear on sun exposed areas of the skin. Most common locations are on the face, arms, and back

Patch

an area of darker skin pigmentation that is usually brown or tan and typically is present at birth (birthmarks). Some of these patch’s fade, but many do not change over time. Flat, nonpalpable, irregular shaped macule more than 1 cm in diameter

clubbing

nail exceeds 180* from hypoxia

turgor

elasticity or firmness of the skin; assessed by gently pinching the skin to check for hydration

Leukonychia

appears as white spots on the nail plate. Usually caused by minor trauma or manipulation of the cuticle.

dehydration

dry, cracked skin and dry mucous membrane

Koilonychia

presents as a thin, depressed nail with the lateral edges turned upward

papule

elevated, firm, less than 1 cm in diameter

plaque

elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter. Examples: psoriasis

Wheal

elevated irregular shaped area of cutaneous edema; solid, transient; variable diameter (insect bites, urticaria, allergic reaction, lupus erythematous)

vesicle

Elevated, circumscribed, superficial, not into dermis; filled with serous fluid (clear fluid). Is less than 1cm in diameter. (varicella/chickenpox, herpes zoster/shingles, impetigo, acute eczema)

Bulla

Vesicle greater than 1cm in diameter. (blister, pemphigus vulgaris, lupus erythematosus, impetigo, drug reaction)

Pustule

Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid (white fluid). (impetigo, acne, folliculitis, herpes simplex)

Keloid

Irregular shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound

Scar

thin-to-thick fibrous tissue that replaces normal skin following injury or laceration to the dermis. (Healed wound or surgical incision)

Excoriation

Loss of the epidermis; linear hollowed out crusted area. (Abrasion or scratch, scabies)

Fissure

Linear crack or break from the epidermis to the dermis; may be moist or dry. (Athletes foot, cracks at the corner of the mouth, chapped hands, eczema)

Ulcer

loss of epidermis and dermis; concave; varies in size (pressure ulcer, stasis ulcers)

Pressure ulcer

localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction.

Zosteriform

pattern where skin lesions appear in a band like pattern along a nerve. Unilateral rash following a dermatome. (shingles, dermatome)

Confluent

When separate skin lesions join together and form a larger area

Who is more likely to have signs of abuse?

those that rely on someone for care like the elderly, babies, etc.

Braden’s scale

determines someone’s risk of pressure sores

When asking about symptoms the nurse should ask what?

the severity and location

Mary went camping in Vermont last week and now she has noticed a rash on her right thigh, and she has been having flu-like symptoms. She presents with a bullseye rash what likely caused this rash?

tick bite which can lead to lime disease

Mary has a red, moist, itchy rash beneath her bilateral breasts. What is the most likely cause of this rash?

Candida as it accumulates it becomes candidiasis which is caused by a fungal infection due to moisture