Skin , Hair & Nails

Nursing 330

Governors State University

Shirley Comer

Skin Assessment- Inspection

Inspect– Wide Spread Color changes

Pallor Erythema Cyanosis Jaundice Pigmentation Changes Freckles Nevus (mole) Birthmarks

– Unusual Odors Hygiene, excessive sweating, urine, musty

Danger Signs ABCDE

Abnormal Characteristics of Pigmented lesions– Asymmetry of a pigmented lesion– Border irregularity– Color variation– Diameter greater than 6mm– Elevation– Enlargement

ABCD Pix

Skin Assessment – Palpation

Use back of hands Hypothermia or Hyperthermia Moisture

– Perspiration normal on face, hands, axilla and skin folds in response to anxiety

– Diaphoresis- perfuse perspiration r/t increased metabolic rate i.e. increased heart rate, pain or fever

Skin Assessment – Palpation cont

Texture- smooth and firm Thickness- thickened areas normal on hands

and feet Edema – Fluid accumulation in the intercellular

spaces– Pitting- finger leaves imprint in area.

Graded subjectively 0+ to 4+ Evident in dependant parts of body

Skin Assessment – Palpation cont

Vascular or Bruising-– Cherry (senile) angiomas- small, smooth, slightly raised, bright red

dots that commonly occur in all adults over 30. Not a significant finding

– Bruising- ask how occurred Multiple bruises at different stages of healing can be a sign of abuse Tattoos- ask about Symptoms of Hepatitis

Hygiene- note cleanliness- free of parasites Turgor- Pinch up a large fold of skin- should return to

normal position rapidly– Decreased in dehydration or extreme wt loss.– Tenting is when skin remains pinched up

Skin Lesions and Decubs

Nail Anatomy Pix

Nails- Inspection

– Capillary Refill- Blanching of nail bed lasts 1-2 seconds. Longer may indicate cardiovascular or respiratory disorder

– Shape and contour Clubbing-congenital or chronic CO2 retention Spooning-concave curves- Fe deficiency Jagged- chronic anxiety Transverse grooves-nutrient deficiency Longitudinal grooves- normal Nail adhered to bed- spongy bed accompanies clubbing Pitting often /c psoriasis Paronychis- swollen tender nail folds-fungal or bacterial infection

Clubbing image

Longitudinal and Transverse Nail Ridges - Photo

Hair Assessment - Inspection

Hair Assessment– Color– Texture– Distribution- male v. female alopecia– Lesions – Hygiene– Parasites

Palpation - Hair

Part hair to look at scalp (wear gloves)– Parasites– Hygiene– Scalp condition– Growth pattern– Alopecia– Lesions– Dandruff, seborrhea, psoriasis, eczema

Hair Loss- Male vs. Female

Commonly seen abnormalities - Petechiae

tiny hemorrhages Less than 2mm Round Purple, red, brown in color /s blanching Present /c thrombocytopenias, endocarditis, septicemia Found on mucus membranes, conjunctiva, abdomen,

buttocks, forearms

Purpura

Extensive patches of Petechiae and ecchymoses

Flat macular hemorrhage Seen /c thrombocytopenia, scurvy In elderly may result from minor trauma Hematoma -Elevated area of bleeding under

the skin

Petechae and Purpura Photo

Infant Assessment

General Pigmentation– Mongolian Spots-Blue, Black and Purple spots on

buttocks or sacrum- common if AA, Native American, Hispanic and Asia newborns.

– Bruising- Common following injuries from rapid, traumatic, or breech births

– Congenital birth marks- Port wine stains, angiomas, Strawberry mark, Cavernous Hemangioma

Common Birthmarks – Port Wine Stain, Hemangioma, Strawberry mark, café au late

spot, mongolian spot

Age specific - children

Petechiae and Hematoma may be present on face r/t prolonged violent crying or coughing

Abuse patterns– Multiple bruises in various stages of healing– Injuries to parts of body covered /c clothing– Marks suggestive of instrument use- belt, cigarette,

pinching, biting

Age specific- children Cont

Common findings– Diaper Dermatitis- red moist diffuse macular– Candidiasis(yeast)- fiery red moist patches with clear borders– Impetigo- Red vesicles rupture to form honey colored crust-

Contagious bacterial infection– Chickenpox (Varicella)- small vesicles evolving to pustules on

trunk spreading to face, and limbs– Ringworm- fungal infection produces scales and can cause

permanent hair loss– Measles (Rubeola)- red macular/papular rash behind ears and

spreads to body– German Measles (Rubella)- Paler lesions than rubeola

Common Childhood findings

Common Findings- Tinea forms, athlete’s foot, ringworm and Jock itch

Common Findings – Rubella, cradle cap, uticaria

Age Specific Children cont

Atopic Dermatitis (eczema) – red papules and vesicles /c weeping, oozing and

crusts– Scalp, forehead, cheeks, forearms, elbows and

back of knees– Family hx of allergies

Seborrheic Dermatitis (Cradle Cap)– Greasy yellow-pink lesions on scalp and forehead– No family hx of allergies

Common Childhood Lesions- Contact dermatitis, Candidiasis, Atopic dermatitis

Age Specific Assessment

Adolescent- increase in sebaceous gland r/t increased acne and oily skin

Pregnant Woman– Striae- Stretch marks. Initially pink then silver– Linea Nigra- Brownish black line abdominal midline– Chloasma- Irregular brown patches on face- aslo /c

oral contraceptives-disappears /p pregnancy ends– Vascular Spider Veins- Capillaries on skin surface

break

Pregnancy – Cholasma, striae, spider veins, linea nigra

Age Specific- Older Adult

Senile Lentigines- Liver Spots- small flat brown macules-r/t sun exposure Venous stars and angiomas Dry Skin- increases in elderly Acrochordons- Skin Tags- overgrowth of normal skin Skin thins- /c decreased sebaceous gland activity and SQ fat Less Elasticity- Tents more Alopecia- genetic- male pattern baldness Hair Greys- r/t decreased melanocyte function Hair Thins- Growth decreases, amount decreases in axilla in pubic areas.

– Women- may develop facial hair /p menopause r/t decreased estrogen

– Men- grow bristly hairs in ears, nose and eyebrows

Common Findings – Senile Lentigines, Skin Tags, Seboratic Keratosis

Age Specific – Older Adult cont

Nails– Growth decreases– Longitudinal ridges– Brittle– Yellowing– Toenails thickened and misshapen r/t chronic PVD

Malignancies

Basal Cell carcinoma- – Most common form of Skin cancer– starts as skin colored papule– Develops pearly borders with red center– Slow growing

Squamous Cell Carcinoma-– Red scaly patch /c sharp margins– 1 cm or more– Develops central ulcer /c surrounding redness– Less common but grows rapidly

Malignancies of AIDS

Epidemic Kaposi’s Sarcoma– 3 stages

Multiple pink patches Lesions develop into raised papules, oval and vary in color Advances are widely disseminated involving skin, mucus

membranes, and visceral organs

Malignancies cont

Malignant Myeloma-– ½ of lesions are pre existing nevi– Brown, tan, black. Red, or purple– Irregular borders

– May scale, flake or ooze– Metastasizes quicker than other forms

Skin Cancer – Basal Cell, Squamous Cell, Kaposi’s, Malignant Myeloma

Other Common Lesions

Folliculitis- superficial infection of hair follicle r/t shaving Psoriasis- Scaly red patches /c silvery scales Herpes Simplex- Cold sore- vesicle then pustule which

erupts Herpes Zoster- Shingles- small groped vesicles then

pustules then crust- develops along nerve path Contact dermititis- Local reaction to irritant- redness

followed by swelling, wheals or uticaria. Allergic drug reaction- red macular rash, generalized.

May proceed to uticaria

Common Findings – Follicuilitis, Herpes Simplex, Cherry angioma, Shingles, MRSA

Common Findings- Fungal infection, ingrown toenail, changes with age

Lyme Disease, Eczema, Rosacea, Vitiligo

Practice Exam Question

Your neighbor calls you to ask your opinion about a sore that won’t heal on his nose. He states it started out as a small red spot and is now about ½ inch irregular red and brown patch. What would you suggest he do?

A. Suggest he see a doctor about the lesion B. suggest he apply an hydrocortisone cream C. Suggest he wait a month and see how it looks D. Suggest he use a good moisturizer

Rationale

A is the correct answer because the lesion description sounds like a malignancy

B and D are incorrect as these products are not appropriate treatments

C. is incorrect as malignancies can grow quickly