Assessment of Skin, Hair and Nails
The nintegumentary system, consisting of the skin, hair, and nails, is the largest norgan of the body and the easiest of all systems to assess. It provides invaluable ninformation about all other bodily systems. The skin, hair, and nails provide nclues about general health, reflect changes in environment, and signal ninternal ailments stemming from other organs. Because integumentary system ncells reproduce rapidly, changes in the skin, hair, and nails may be an early nwarning of a developing health problem. Yet, the importance of carefully nassessing the integumentary system for subtle changes is often overlooked. A nthorough assessment of this system may help you detect actual or potential nproblems, not only in the skin but also in underlying systems.
Anatomy and Physiology nReview
Before nyou begin your assessment, you need a basic understanding of the integumentary nsystem, including its general function and purpose. A knowledge of normal nfunctions and structures will enable you to detect and interpret any nabnormalities.
Structures and Functions of the Integumentary System. nThe structures of the integumentary system are the skin, hair,nails, nsweat glands, and sebaceous glands. Their functions are described in the nfollowing paragraphs.
The Skin. The skin is a layer of tissue that covers all nexposed body surfaces. Although similar to the mucous membranes, the skin also nincludes appendages such as hair follicles and sebaceous glands. Its thickness nvaries according to location or site.The epidermis, nthe outer visible layer, contains keratin, an extremely tough, protective nprotein substance that can cause tissue to become hard or horny. The deeper ndermis is made up of proteins and mucopolysaccharides, nthick, gelatinous material that provides a supporting matrix for nerve tissue, nblood vessels, sweat and sebum glands, and hair follicles. Beneath the dermis nlies the subcutaneous layer, made up of nfatty connective tissue. Together, the layers of the skin protect underlying nstructures from physical trauma and ultraviolet (UV) radiation. The skin is nessential to maintaining body temperature, fluid balance, and sensation. nIt is involved in absorption and excretion, immunity, and the synthesis of nvitamin D from the sun (Fig. 10.1).
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The Hair. The hair nis also made up of keratinized cells. Hair is found over most of the body. It ngrows from hair follicles supplied by blood vessels located in the dermis. Vellus, which is short, pale, and fine hair, is nlocated over all of the body. Terminal hairs, which are dark and coarse, are nfound on the scalp, brows, and, after puberty, on the legs, axillae, and perineum.The texture and color of hair are highly variable.Hair provides protection by covering the scalp and nfiltering dust and debris away from the nose, ears, and eyes.
The Nails. Nails are made up of hard, keratinized cells and ngrow from a nail root under the cuticle. Other nail structures include the free nedge,which overhangs the tip of the finger or ntoe; the nailbed, or epithelial layer of skin; and nthe lunula, the proximal part of the nail. The nailbed’s vascular supply gives the nail a pink color, nalthough the nail itself is generally transparent. The purpose of the nails is nto protect the distal portions of the digits and aid in picking up objects n(Fig. 10.2).
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Other Structures. Other appendages to the integument ninclude the sweat glands and sebaceous nglands. There are two types of sweat glands: eccrine nglands, which are distributed over much of the body, and apocrine glands, which are limited to the genitalia, axillae, nand areolae. Sebaceous glands are located near hair follicles, over most of the nbody. They secrete sebum, which nlubricates the hair shaft.
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Interaction With Other Body Systems. Changes ithe integumentary system may reflect a problem in any of the systems ndescribed in the following paragraphs.
The Respiratory System. The respiratory system is nresponsible for obtaining the oxygeecessary for cellular metabolism, as well nas for eliminating the carbon dioxide produced through the metabolic processes. nIf the process of respiration is impaired, alterations in the skin are most noften evident through the development of cyanosis, a bluish discoloration, as nhemoglobin becomes unsaturated with oxygen. Central cyanosis occurs when oxygesaturation is less than 80 percent and results in diffuse changes in the skiand mucous membranes.
Icontrast, peripheral cyanosis, which occurs in response to decreased cardiac noutput, is evident in areas of the body such as the nailbeds nand lips, which are cooler than other regions; it may also be evident when aindividual is chilled. In severe and chronic cardiopulmonary diseases, clubbing nof the nails occurs owing to hypoxia (Fig. 10.3).
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The Cardiovascular System. The skin layer also contains a nnetwork of blood vessels, which contribute to its ability to regulate ntemperature and obtain nourishment.Alterations in the ncardiovascular system can lead to circulatory impairment and changes in skicoloring and temperature, as well as to the development of lesions, ulcerations, and necrosis.When ncardiac output is decreased, cyanosis may develop.
The Gastrointestinal System. The primary roles of the ngastrointestinal (GI) system are the conversion of food to absorbable nutrients nand the elimination of wastes. When GI disorders impair the body’s ability to nexcrete toxins, the accumulation of toxins may become evident in the skin. For ninstance, when bile excretion is impaired so that bile builds up, jaundice, a nyellow discoloration, often results. When dietary lipids accumulate, xanthomas,which are lipid deposits, or papules may develop. nNutritional deficits, which may stem from GI problems, are often evident in the nskin. For example, deficits in vitamin A, riboflavin, vitamin C, iron and nprotein may all result in skin,hair,or nail nalterations.
The Urinary System. The urinary system is primarily nresponsible for filtering the blood, but it is also involved in the productioof red blood cells and the regulation of electrolyte and fluid status.When renal function is altered and filtratiodecreases, toxins and fluids build up in the body.The ntoxins often include pigmented metabolites,which nalter the skin coloring. For example, an increased concentration of urea may nlead to a residue of urea on the skin, which is called uremic frost. Toxins are nalso responsible for the development of npruritus, or itching. Calcium deposits may lead to excoriations of the skin.Altered hematologic status may be evident through ecchymoses and hematomas. Increased fluid volume nassociated with diminishing renal function may result in edema.
The Neurological System. The skin contains an intricate system nof sensory and autonomic nerve fibers and serves as the body’s largest nsensory organ. Not only does this network of fibers permit the sensations nof touch, temperature, pressure, vibration, and pain, the autonomic nervous nsystem fibers control the skin’s blood vessels and glands, regulating the nskin’s temperature, moisture, and oiliness.Alterations nin the nervous system can have profound effects on the skin, placing it at risk nfor injury or discomfort. For instance, if sensation is decreased, a person is nmore likely to experience trauma to the skin because he or she is less likely nto detect the need to withdraw from potentially dangerous objects or nactivities. Irritated nerves can produce disagreeable sensations in the skin, nsuch as burning. Alterations in the autonomic nervous system can result idrying of the skin.
The Endocrine System. Alterations of the endocrine system nmay affect the skin in myriad ways.Diabetes leads to nalterations in skin integrity through complex processes involving changes ithe immune,vascular,and neurological systems.Diabetic foot ulcers are examples of altered skiassociated with diabetes. When thyroid disease occurs, the skin is ofteaffected. In hypothyroidism, the skin is often dry and cool and becomes puffy,with nonpitting edema. It nmay develop a yellow hue as carotene naccumulates. The hair is affected, becoming dull, brittle, and sparse. Icontrast, hyperthyroidism causes the skin to be warmer, sweatier, and smoother nthan usual. The nails are thin and brittle and may separate from the nail nplate. The hair is fine and silky, with patchy hair loss. Adrenal ndiseases affect the skin, hair, and nails. Hypofunction nof the adrenals can result in nhyperpigmentation of the skin (a bronze color) and alopecia (baldness). Hyperfunction results in thin and fragile skin, petechiae, plethora, bruises, and poor wound healing.
The Lymphatic/Immune System. The immune system is involved nin protecting the body from both external and endogenous factors. Impairments nin the immune system are reflected in the skin when infectious diseases nresult in their typical rashes or lesions. Abnormalities of the immune system ncan also result in hypersensitivity and the development of atopic, nor allergic, skin changes, including npruritus or rashes such as atopic ndermatitis or psoriasis. Skin changes are also common in some systemic nautoimmune disorders such as lupus erythematosus.
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Developmental, Cultural, nand Ethnic Variations
Infants. Various differences can be noted ithe newborn skin. Infants have very smooth skin, partly because of their lack nof exposure to the environment, but also because there is less subcutaneous ntissue. Color changes can be readily seen. Newborns often appear pinker or nredder because of the lack of subcutaneous tissue.Physiological njaundice may occur 2 to 3 days after birth as a result of the breakdown of nexcessive red blood cells at birth and immature functioning of the liver. nNewborns have little or no coarse terminal hair. They shed their hair at napproximately 3 months and it is soon replaced.
Eccrine sweat glands nbegin to function within a month after birth.The nimmature sweat glands lead to poor thermoregulation. With no functioning apocrine sweat glands, babies’ skin is less noily than adults’ and lacks offensive odor. The secretion of sebum by the sebaceous glands can result icradle cap, seborrheic dermatitis, thick nyellow-crusted lesions. Numerous skin lesions may also be seen on the newborn, nsuch as mongolian spots, nevus flammeus n(port-wine stains), capillary hemangiomas (stork nbites), hemangioma simplex (strawberry marks),milia, and erythema toxicum neonatorum.
Adolescents. Adolescence is a time of rapid nhormonal change that may affect the integumentary system. During adolescence, nthe apocrine glands begin to enlarge and function.At nthis time, young people develop increased axillary sweating and the potential nfor a more pronounced body odor. The sebaceous glands increase sebum productioand the skin becomes more oily, leading to the onset of acne. During adolescence, pubic and axillary nhair and male and female body hair patterns become apparent.
Pregnant Women. During pregnancy, there is increased nblood flow to the skin, particularly to the hands and feet, as peripheral nvessels dilate and the number of capillaries increases to dissipate heat. Along nwith this increased flow, there is an increase in sweating and sebaceous nactivity. The skin thickens and separates with stretching,with nthe appearance of striae. nHormonal changes result in hyperpigmentation. The pigmentary nchanges occur on the face resulting in chloasma, on the abdominal midline (the linea nalba becomes the linea nnigra) and on the nipples, areolae, axillae, and nvulva.
Menopausal Women. During menopause, hormonal fluctuations nresult in hot flashes, often accompanied by flushing of the skiand increased pigmentation. There may be an increase in facial hair and some ndegree of scalp hair loss. Chloasma may occur. The nincidence of skin tags increases at menopause.
Older Adults. With age, the skin atrophies. There nis a decrease in production of sebum and sweat. The skin becomes drier and flattens,often becoming paperlike.The nelasticity decreases and wrinkles develop.There is a ndecreased melanocyte function, so that the hair grays and the skin becomes more npale. Target areas of increased melanocyte function result in “age spots.”There is a decrease in axillary,pubic, nand scalp hair.Women may experience increased facial nhair as estrogen function is lost; men experience an increase iasal and ear nhair growth. The nails grow more slowly and become thicker and more brittle.
Furthermore, nspecific skin lesions are more common in elderly persons, including:actinic keratoses, nbasal cell carcinomas, seborrheic keratoses, nstasis ulcers, senile pruritus, and keratotic horns.
People of Different Cultures and Ethnic Groups. nCultural and ethnic variations can readily be seen in the integumentary system.Genetic factors determine the skin color. The ngreater the amount of melanin, the darker the skin color. Assessing for subtle nchanges in the skin becomes more of a challenge the darker the skin color. The noral mucosa is best for assessing color changes in dark-skinned people. Also, nassessing the sclera for jaundice is more accurate than assessing the skin ian Asian person. Fair-skinned persons of Irish, German, or Polish descent have nan increased risk for skin cancer with prolonged sun exposure. AfricaAmericans have a higher incidence of keloids, pseudofolliculitis, nand mongolian spots.
Differences nin hair can also be readily seen with different ethnic groups. Asians oftehave black, straight, silky hair,and Chinese men have nvery little facial hair.The hair texture of AfricaAmericans is often thick and kinky. Cultural variations may also be noted ithe amount of sweat production. For example, Asians produce less sweat and ntherefore have less body odor. Be alert to your patient’s ethnicity wheassessing the integumentary system; changes may be culturally related rather nthan an indication of pathology.
Performing the nIntegumentary Assessment
Assessment nof the integumentary system includes a comprehensive health history and nphysical examination.The history identifies any nsymptoms related to the integumentary system, risk factors for skin problems, nand the presence of diseases in other systems that could contribute to skin problems.The physical examination identifies the ncurrent condition of the integument, including any abnormal function. nThroughout the assessment, be attentive to signs or symptoms of both actual and npotential problems of the integument.
Health History. The health history includes nobtaining biographical data and asking questions about the patient’s current nhealth, past health, and family and psychosocial history. It also involves a nreview of systems. If you don’t have the time to perform a complete health history,make sure to at least perform a focused health nhistory of the integumentary system.
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Biographical Data. Briefly review all nbiographical data. Identify your patient’s age; skin function varies by age, nand certain skin diseases are more likely to develop at particular ages. For nexample, papules, vesicles, and pustules associated with impetigo are mostly nseen in children; acne frequently occurs during puberty, and plaques and malignancies are more common iolder adults. Your patient’s occupation and recreational activities can provide nclues regarding the potential for exposures to harmful chemicals, trauma, or nenvironmental hazards.Exposure to chemicals may cause na contact dermatitis. Excessive sun exposure from either work or play may nincrease the risk for skin cancer.Similarly, the npatient’s living situation can suggest environmental exposures to factors that nmight be harmful to the skin.
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Current Health Status. If the patient has a specific nskin complaint, analyze it as you begin your history, using the PQRST system. nThe major complaints to be alert for include: changes in moles or other lesions,nonhealing sore or ulcer or chronic irritation, npruritus/itching, and rash, a very common complaint. Because the integumentary nsystem also includes the hair and nails, a symptom analysis should focus ochanges in these areas. Generally, the problems that trigger integumentary ncomplaints are of a stable nature and not life-threatening, and so you will be nable to proceed with the full history and physical. If the patient is overly ndistressed by the symptoms (e.g., severe itching or fear of malignancy), focus first non the presenting problem and perform a comprehensive history at a later time.
Symptom Analysis. Symptom analysis tables for the nsymptoms described in the following nparagraphs are available for viewing and printing on the compact disc that came nwith the book.
Change in Mole or Lesion. nSkin cancer is the most common type of cancer, and changes in a mole (nevus) or nskin lesion can often evoke fear in the patient. Although there are many types nof lesions, most of which are benign, it is important to be able to detect skicancer at its earliest stages,when treatment yields nthe best results. There are three types of skin cancer: basal cell and squamous ncell carcinomas, which affect the epidermal keratinocytes, and melanoma,which affects the melanocytes of the basal layer nof the epidermis. Sun exposure is a risk factor in all types.
The nmajority of skin cancers are basal cell. Basal cell carcinomas are directly nrelated to sun exposure,with 90 percent of lesions noccurring on the head and neck. Basal cell carcinomas are easily treated and nrelatively benign. Squamous cell carcinoma is often preceded by actinic nkeratosis (premalignant macule or papule of rough, sandpaper texture, caused by nexcessive UV exposure). Sixty-six percent of these lesions occur on sun-exposed nareas and respond well to treatment. Even though melanoma occurs less nfrequently than basal cell and squamous cell carcinomas, it is the most deadly ntype of skin cancer.Congenital nevi and dysplastic nnevi may be precursor lesions to melanoma.
Unfortunately, nthere are usually no symptoms associated with skin cancers unless the lesiohas metastasized regionally or distantly. In these cases, various symptoms nmight be present related to whether a lesion, for instance a malignant nmelanoma, had metastasized to another organ such as the bowel, lung, liver, or nbrain.
Nonhealing Sore or Chronic nUlceration. When your patient’s history includes a sore that nwon’t heal or a chronic ulceration, the routine symptom analysis questions will nprovide a good picture of the lesion and any previous self-treatment applied. nKeep in mind that a nonhealing wound or chronic irritatiois often associated with an underlying disease. The most common types of nonhealing wounds or chronic skin ulcerations are caused by nvascular disease or pressure or by diabetes.
Pruritus. nPruritus is severe itching. It may be localized or generalized and caused by a ndermatologic problem or underlying systemic problem.Pruritus nis often accompanied by a rash. Itching, wheot associated with a rash, may nbe indicative of significant systemic disease or simply dry skin.
Itching narises from free nerve endings (nonmyelinated), which nare especially abundant in the flexor aspects of the wrist and ankles. It noccurs as a result of a spinal reflex and external stimuli, such as heat, ndryness, inflammation, and vasodilation. Psychological factors, such as ndepression, can influence the perception of itching,which nexplains the varied responses to it.A thorough nsymptom analysis will help you to pinpoint the underlying cause.
Rashes. nRashes, like itching, may be localized or generalized, acute or chronic, and ncaused by an obvious dermatologic problem or an underlying systemic problem.A thorough symptom analysis will help you to npinpoint the problem and direct your physical assessment.
Seasonal Skin Disorders. nCertain skin disorders are more common during one time of year than others. nSeasonal skin problems include those caused by temperature fluctuations, nair humidity, and exposure to contaminants. It is important to remember,however, that although these problems may be more ncommon at certain times of the year, they may appear at any time.
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Hair Changes. nHair loss (alopecia) is probably the nmost distressing change in hair that can occur because of its cosmetic effect.Alopecia not only refers to scalp hair but also to nbody hair. Normally hair growth is cyclical,with 85 nto 90 percent of scalp hair in the growth phase n(anagen), and the remaining 10 to 15 percent nin the resting phase (telogen). Scalp hair grows about 0.25 mm/d, and about 100 nstrands of hair are lost per day.
Hair nloss can occur for many reasons.Alopecia can be nclassified as scarring or cicatricial (resulting from injury such as burns, nradiation, or traction with irreversible damage to the hair follicles) and nonscarring or noncicatricial n(resulting from hormonal changes, medications, infectious diseases, or thyroid ndisease, in which the follicles remain intact with a potential to reverse the nprocess).
Nail Changes. Changes nin the nails also often reflect an underlying systemic problem.Changes in color and texture are frequent complaints.A symptom analysis will help you identify any nunderlying problems.
Past Health History. The past health history allows you nto determine what illnesses or problems the patient has had in the past, nincluding those related to the skin,hair,or nails. It nadditionally permits you to determine episodes of illnesses involving other nsystems that might have an impact on the integument.
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Family History. The family history allows you to ndetermine what, if any, integumentary problems are common to the patient’s nfamily members.Diseases of the integument are as nlikely as others to have a familial predisposition. The history also helps to nidentify familial diseases that directly affect other systems and that might nhave some affect on the skin. This portion of the nhistory also begins to explore the potential for problems stemming from the npatient’s living environment.
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Review of Systems. The review of systems is extremely nimportant when exploring a complaint related to the integumentary system. It nhelps you identify problems in other systems that directly affect the skin, nhair, and nails. Health problems directly affecting many systems can have nprofound effects on the integument.The review of nsystems is also useful in prompting the patient to identify problems that she nor he previously felt were not related or worth mentioning.
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Psychosocial Profile. The psychosocial profile nserves several purposes. It provides important information regarding dietary nand other habits, as well as occupational, social, and recreational activities nthat could influence the condition or health of the skin, hair, and nnails. It provides an opportunity to explore the patient’s self-care and social nactivities,which may identify his or her response to nan integumentary system problem.
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Physical Assessment. Once you have taken the history,proceed to collect objective data through your nphysical examination.Even though the skin,hair,and nails are easily accessible and we look at nthem every day, you still need to be very objective and attentive to details nthat could easily be overlooked.
Approach. The techniques used in the examination of the nintegument are inspection and palpation.As you nconduct the assessment, along with your sense of sight and touch,use nyour sense of smell to note any unusual odors. It is important to inspect all nareas of skin, including intertriginous areas, which nlie between or under folds of skin.
Throughout nthe examination, compare symmetrical parts. Also be aware of the “feel” of the nskin, hair, and nails.You can inspect the skin in one nof three ways:
1. Using a head-to-toe approach.
2. Observing all skin on the anterior, posterior, and nlateral surfaces of the body.
3. Inspecting the skin by regions, as you examine the ncardiovascular, respiratory, and other systems.
Regardless nof your approach, a complete examination is necessary,and na systematic approach will help you avoid omissions. During the examination, nkeep in mind the underlying structures or organs because they may explaichanges in the overlying skin. Also compare exposed with unexposed areas.Variations might be signs of “wear and tear,” poor nalignment, or injury, or they may indicate the need for further history.
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Performing a General Survey. A general survey of the nintegumentary system is typically done while obtaining the health history. Be nattentive to any signs that suggest alterations in the integrity of the skin, nhair, and nails. During the early observation phase, note general skicoloring, as well as any obvious variations by region.Coloring nis a highly variable feature,even among people of the nsame race or ethnic background. Variations can indicate sun or chemical nexposure, emotional responses, illness, or just a personal characteristic. Also nobserve the general distribution of the hair, including its condition, color, nand sheen.Note the general condition of the nails. nThe examination also relies on your sense of smell and touch. Be attentive for nany unusual odors.As you shake the patient’s hand or ntake vital signs, check the temperature and moisture of the skin.
Iaddition, consider the patient’s overall skin condition in comparison with her nor his stated age. If the skin appears chronologically older, it may have beeaged by chronic illness, substance use, or environmental exposures. Exposure to nsunlight increases the risk of malignancy; exposure to chemicals increases the nrisk for various forms of dermatitis. Also do the following:
■ Determine the patient’s overall nutritional status. nSigns of nutritional deficiencies are often evident on inspection of the nskin, hair, or nails.
■ Note the patient’s apparent emotional status.This provides insight into his or her ability to ncope with any real or perceived disfigurement associated with alterations nin the integument. It may also suggest the likelihood that lesions might be nself-inflicted.
■ Be aware of the patient’s overall body nhabitus—weight distribution,posture, and muscle mass.Besides providing information outritional status, nthis suggests other health problems that influence the skin. For ninstance, a person who has truncal obesity and a ntripod posture (sitting leaning forward on elbows) may have chronic lung ndisease requiring systemic corticosteroid treatment. Lung disease may be reflected nby nail clubbing and cyanosis; corticosteroid therapy may cause the skin to nthin and become friable.
■ Obtain the patient’s vital signs. Elevations nin temperature may indicate an infection that might be accompanied by a rash or nother skin lesion.
Performing a Head-to-Toe Physical Assessment. nNext, do a head-to-toe survey, checking for more specific signs of ndiseases affecting other organ systems that might alter the skin, hair, or nnails.
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Performing an Integumentary Physical Assessment. Once the ngeneral survey and head-to-toe assessment are completed, begin the focused nexamination of the skin, hair, and nails, using inspection and palpation. For npurposes of simplicity, inspection and palpation are discussed separately below.However, rather than inspecting all areas of skin, nhair, and nails, and then palpating all areas and suspicious lesions, you are nmore likely to inspect and palpate specific areas almost simultaneously. nAs you read the following information, keep in mind that areas that vary from nnormal should be explored using palpation.
Assessing the Skin. nUse inspection and palpation to examine the skin.
Inspection. nExamine the patient’s skin,noting color,odor,and nthe presence of lesions. Once you have determined the patient’s overall skicoloring, take a moment to decide if the coloring suggests something other thaa normal variation.
Assessing Color. nIn addition to alterations in general coloring, it is normal for various nregions of a person’s skin to differ in color,depending nprimarily on the amount of exposure to light. These variations are generally nsymmetrical. If you notice that one area—for instance, the shoulders or arms—is ndarker than other areas—such as the anterior chest or buttocks—make sure that nthe difference is symmetrical or explained. For instance, a long-distance truck ndriver’s left arm might be darker than the right because that arm receives ngreater sun exposure during daylight driving hours. (See Skin Color Variations.)
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Assessing Lesions. The nskin should be a continuous tissue, and so note breaks, erosions, or lesions. nDocument localized and/or pigmented variations, including moles, freckles, or nvascular lesions, and examine them closely.
Use na flashlight or penlight and a magnifier to determine the surface,pigmentary,or border characteristics of many nlesions, particularly when they are small. Besides providing brighter light to na specific skin area, the penlight or flashlight can also be used nto shed tangential or oblique light to a lesion. Tangential lighting will cause nthe distal edge of the lesion to cast a shadow if the lesion is raised.Another use of the light is to transilluminate na lesion.For very small lesions,you nwill need either a small-beam penlight or a transilluminator nattachment for an otoscope or ophthalmoscope. Transillumination of a raised lesion helps determine nwhether the lesion is solid or fluid filled. Fluid-filled nlesions have a yellow or pink glow,whereas solid nlesions do not.
Use na transparent ruler with centimeter markings to measure any lesions you detect. nClean the ruler after each use,using the method nrecommended by your facility. Either the transparent ruler or a glass slide cabe used as a diascope to determine whether or not a nvascular lesion blanches.Press the ruler or slide ngently against the lesion, noting whether it blanches or pales with the npressure.
Vascular nlesions are red to purple in color. They may be caused by an extravasation of nblood into the skin tissue or by visible superficial vascular nirregularities.
Always nbe attentive to the signs of malignant melanoma when assessing a skin lesion. nThe warning signs are easily recalled using the mnemonic “ABCD.”Any ntime a patient indicates that a pigmented area has newly developed or changed nsignificantly from its original appearance, you must be alert to the npotential of malignancy. In addition to malignant melanomas, several other ntypes of skin malignancies are less aggressive and less likely to be fatal n(Figs. 10.4 and 10.5).
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If nyou detect a lesion, inspect it closely and palpate it to determine its characteristics.Decide whether it represents a primary or nsecondary skin lesion. A primary lesion is one that appears in response to some nchange in the internal or external environment of the skin and is not altered nby trauma.Primary lesions are categorized by whether nor not they are raised and by their overall dimensions. Different sources use ndifferent dimensions (0.5 or
Secondary nlesions result from changes in primary lesions.They neither add to or take away from an existing primary lesion.
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Pressure Ulcers. Pressure nulcers are a type of secondary lesion caused by unrelieved pressure.Healthy nPeople 2010 has established a goal of reducing pressure ulcers iursing homes nby 50 percent to 8 per 1000 residents from 16 per 1000 residents reported i1997. Assessment begins with identifying those at risk for pressure ulcer ndevelopment and developing a plan to prevent pressure ulcer formation. If a npressure ulcer develops, assessment focuses on staging pressure ulcers and ndeveloping and evaluating pressure ulcer treatment plans.
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Lesions nmay also be categorized according to their pattern, configuration, and ndistribution.
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Palpation. After inspecting the skin, explore any findings nthrough palpation. Palpation is used to determine the skin’s temperature,moisture, texture, and turgor. It can also help nto determine whether a localized lesion is raised, indented, or pedunculated and its surface characteristics.
As nyou palpate for temperature, you will find that the dorsal part of your nhands and your fingers are most sensitive to temperature variations. nRemember to wear gloves when palpating any potentially open areas of the skin.
The nskin’s moisture varies among body parts, as well as with changes in the nenvironmental temperature, physical activity,or body temperature.Perspiration is produced to cool the body. Ithe winter, the skin tends to be drier because of the lower ambient temperature nand decreased humidity in the environment.
Turgor nis assessed as an indication of elasticity. To determine turgor,pinch na fold of skin over an unexposed area, such as below the clavicle, or on the nabdomen or sternum. You may also use the forearm. Do not test turgor on the ndorsal hand or other areas where the skin is noticeably loose or thin. As you npinch the skinfold, it should feel resilient, move easily, and return to place nquickly when released.
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Assessing the Nails. Assess the nails through inspectioand palpation.
Inspection. nThe condition of the nails often provides important clues about the patient’s noverall health status. Inspect the color and shape of the nails.The ncolor beneath the nails should be similar to the overall skin coloring, nalthough somewhat rosier.There should be no nhemorrhage. Nail texture should be uniform and not brittle. Note any grooves or nlines in the nail or nailbed. Also assess for clubbing, or loss of the normal angle (Lovibond’s angle) between the nail base and the finger.When no clubbing is present, the nailbed is firm. You can further assess for clubbing nby having the patient place the dorsal aspect of two opposite distal fingers ntogether, so that the nails rest against one another. In the absence of nclubbing, you should be able to detect a window of light caused by the space ncreated by Lovibond’s angle.
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Palpation. nPalpate the nail for texture and refill.Nail ntexture should be uniform and not brittle. Note any grooves or lines or pitting nin the nail or nailbed.To check for capillary refill, npress on the tip of the nail. It should blanch, and upon release the color nshould return within 3 seconds.
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Assessing the Hair. Assessing the hair is done by ninspection and palpation.
Inspection. nInspect the hair for distribution, color, and condition of the scalp.Note any increased hair growth or areas of thinning nor alopecia.Also, assess the body for normal ndistribution of hair.The color of the hair can be nvery difficult to assess, primarily because so many people color their nhair. Inspect the scalp as you would any area of skin, assessing any lesions nfor size, relationship to the overall scalp plane, color, and surface integrity.A morphological description of individual lesions noften provides clues to their cause. Almost any of the common skin disorders ncan affect the scalp. Note whether there is any adherent material on the hair. nSmall 1- to 2-mm white eggs are found with lice or pediculosis, nwhich occurs on the hairs of the scalp, beard, axillae, or pubic areas.Although head lice can be seen with the naked eye, nthey are quite small and mobile and their eggs, called nits, are easier to see. Nits are deposited nnear the base of the hair shaft, so that fresh nits are usually found within 1⁄8 ninch of the scalp or skin. When an infestation of lice has persisted for some ntime, or if nits were not removed from an earlier infestation, they will be nfound along a greater portion of the hair shaft because the hair will have ngrown during the period. Nits found 1⁄4 inch or more from the skin have nprobably already hatched.
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Palpation. nPalpate the texture of the hair. If it is unusually coarse or fine, nconsider a thyroid disorder.
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Nursing Diagnoses. Next, consider all of the data you nhave collected during your assessment of Mrs. Green. Use this information to nidentify a list of nursing diagnoses.Some possible nnursing diagnoses are provided below. Cluster the supporting data.
1. Health-Seeking Behaviors, related to the fear of nskin cancer
2. Risk for Impaired Skin Integrity
3. Fear, related to family history of skin cancers
Identify nany additional nursing diagnoses.
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SUMMARY
■ nThe integumentary system provides invaluable information about your patient’s noverall health status.Therefore it is important that you nlearn to objectively assess the skin, hair, and nails and be aware of the wide nrange of normal variations,which further differ naccording to age, race, and ethnic background.
■ nDuring your assessment, use a consistent approach and make careful observations nabout the overall integrity of the tissues, as well as any specific areas nof abnormality.
