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PRINCIPLES TO REMEMBER
- Any break or disruption of the skin predisposes the client to infection.
- The hydration of the skin and mucous membranes reveals the body’s ability to regulate body temperature.
- Skin temperature changes can reflect alterations in blood flow.
- Specific skin conditions or underlying diseases may be detected.
- Condition of the skin reflects the level of a person’s hygiene THREE ESSENTIAL REQUIREMENTS OF A GOOD PHYSICAL EXAMINATION
- Patient must be completely undressed but dressed in an examining gown
- Adequate illumination Preferably natural illumination or bright overhead fluorescent lighting
- A thorough examiner Hair, nails, and mucocutaneous regions must be included KEY POINTS TO REMEMBER Inspect skin color, temperature, moisture and texture Check skin for integrity Be alert for skin lesions Evaluate hair condition, loss or unusual growth Note nail bed condition and capillary refill CLIENT PREPARATION Ask the client to remove all clothing and jewelry then put on the examination gown. Ask the client to remove nail enamel, artificial nails, wigs, and hairpieces as appropriate. Provide clear and appropriate instructions. Position: sitting on the examination table or bed; lateral or prone for assessing skin on buttocks and dorsal surfaces of legs.
TYPES OF LESIONS
Primary Lesions Macule Patch Papule Plaque Vesicle Pustule Nodule Tumor Secondary Lesions Crust Scales Fissure Ulcer Erosion USE OF FOUR MANEUVERS IN DERMATOLOGIC PHYSICAL EXAMINATION - IPPA INSPECTION Inspect general skin coloration While inspecting skin coloration, note any odors emanating from the skin Melanin pigments account for skin color intensity Inspect for color variations Inspect localized parts of the body, noting any color variation A. DESCRIPTION Note the type of lesions Primary - original lesions from previously normal skin Secondary - originates from primary skin lesions Vascular skin lesions - lesions associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic disease Note the color Diffused Circumscribed
Skin Color Abnormalities Color Condition Cause Assessme nt Location Cyanosis Increased amount of deoxygenat ed hemoglobi n, associated with hypoxia Heart or lung disease; cold environme nt Nail beds; lips; mouth; skin Pallor Reduced amount of oxyhemogl obin Anemia Face; conjunctiv a; nailbeds Reduced visibility of oxyhemogl obin as a result of decreased blood flow Shock Skin; nail beds; conjunctiv a; lips Congenital or autoimmun e condition causing lack of pigment Vitiligo Patchy areas on the skin Jaundice Increased deposition of bilirubin in the tissues Liver, gallbladder , or pancreatic disease; destruction of RBC Erythema Increased visibility of oxyhemogl obin as a result of dilation or increased blood flow Fever; direct trauma; blushing; alcohol intake Face; area of trauma Tan- brown Increased amount of melanin Suntan; pregnancy or Addison’s Areas exposed to the sun; face; disease areola; nipples Ecchymos is Extravasion of blood into the subcutaneo us tissue Trauma or fragile blood vessels Extremitie s, head, or trunk in areas easily exposed to injury INSPECTION Check skin integrity Give special attention to pressure point areas Use a scale to document the degree of skin breakdown if present For obese clients: inspect skin on limbs, under breasts, and the groin area A. DESCRIPTION Note the configuration (shape or individual lesions) (^) Linear or serpiginous Grouped or polycyclic Annular or target-like Note the arrangement of multiple lesions Discrete Confluent Randomized Note the size B. DISTRIBUTION Note the extent of involvement Localized or generalized Pattern or symmetry Unilateral or bilateral Characteristic Pattern Cleavage line Dermatomal line DISTRIBUTION OF LESIONS
Stages of Pressure Ulcers Stage I: Persistent non-blanchable erythema of intact skin. In darker skin tones, ulcer may appear with persistent red, blue, or purple tones. Most common of all pressure ulcers. “At risk” person Stage II : Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an erosion, blister, or vesicle. Stage III : Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tnedon, joint capsule) Undermining and sinus tracts may also be present. COMMON SKIN VARIATIONS Freckles (^) Vitiligo Striae Scar Seborrheic Keratosis Mole / Nevus Cutaneous tags Cutaneous horns Cherry Angiomas PRIMARY SKIN LESIONS
- Macule and Patch
- Papule and Plaque
- Nodule and Tumor
- Vesicle and Bulla
- Wheal
- Pustule
- Cyst Skin lesions that originates from previously normal skin Directly associated with a disease process Rarely specific to a single disease
Macule (Latin, a “spot”) Patch A circumscribed, flat lesion that differs from surrounding skin because of its color. May have any size or shape Macule: <1cm Patch: >1cm Examples: Freckles Flat moles Petechiae Rubella Vitiligo Port wine stains Ecchymosis Papule (Latin, “a small swelling”) Small. Solid elevated lesion less than 1 centimeter Plaque (Dutch, “A slab of wood”) Mesa-like elevation that occupies a relatively large surface area compared with its height. Size: Greater or equal to 1 cm Examples: Papules: Elevated nevi Warts Lichen planus Plaques: Psoriasis Actinic keratosis Nodule Elevated, solid, palpable mass Depth of involvement, rather than diameter, differentiate a nodule from a papule Nodule: 0.5-2cm; circumscribed Tumor A solid or cystic elevation or palpable lesion 2. cm or more in diameter Examples: Nodules: Lipoma Squamous cell carcinoma Poorly absorbed injection Dermatofibroma Tumors: Larger lipoma Carcinoma Vesicle and Bulla These are two types of blisters – circumscribed, elevated fluid-filled lesion which may contain serum, blood, lymph or extracellular fluid Vesicle: <1 cm Bulla: >1 cm Examples : Vesicles : Herpes Simplex/Zoster Varicella (Chickenpox) Poison Ivy Second-degree burn Bulla : Pemphigus Contact dermatitis (^) Large burn blisters Poison ivy Bullous impetigo
Scar (Cicatrix) Skin mark left after healing of wound or lesion Represents replacement by connective tissue of the injured tissue Young scars: red or purple Mature scars: white or glistening Examples : Healed wound Healed surgical incision Fissure Linear crack in the skin May extend to the dermis Example : Chapped lips or hands Athlete’s foot Scales Flakes secondary ti desquamated, dead epithelium Examples: Dandruff Psoriasis Dry skin Flakes may adhere to skin surface Color varies ( silvery, white ) Texture varies ( thick, fine ) Pityriasis Rosea Crust Dried residue of serum, blood, or pus on skin surface Large adherent crust is a scab Examples : Residue left after vesicle rupture Impetigo Herpes Eczema Keloid Hypertrophied scar tissue Secondary to excessive collagen formation during healing Elevated, irregular, red Greater incidence in African Americans Examples : Keloid of ear piercing Keloid of surgical incision
Atrophy Thin, dry, transparent appearance of epidermis Loss of surface markings Secondary to loss of collagen and elastin Underlying vessels may be visible Examples : Aged skin Arterial insufficiency Lichenification Thickening and roughening of the skin Accentuated skin markings May be secondary to repeated rubbing, irritation, and scratching Examples : Contact dermatitis, often resulting from exposure to aero allergens, chemicals, foods, and emotional stress VASCULAR SKIN LESIONS
- Petechia (petechiae - plural)
- Ecchymosis (ecchymoses - plural)
- Hematoma
- Cherry angioma
- Spider Angioma
- Telangiectasis (venous star) Petechia (petechiae - plural) Round red or purple macule Small: 1-2 cm Secondary to blood extravasation Associated with bleeding tendencies or emboli to skin Ecchymosis (Ecchymoses - plural) Round or irregular macular lesion Larger than petecia Color varies and changes: black, yellow, and green hues Secondary to blood extravasation Associated with trauma, bleeding tendencies Hematoma A localized collection of blood creating an elevated ecchymosis Associated with trauma
HAIR AND SCALP ASSESSMENT
INSPECTION AND PALPATION
Inspect for general color and condition Inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions Inspect amount and distribution of scalp, body, axillae, and pubic hair NAIL ASSESSMENT INSPECTION Inspect nail grooming and cleanliness Inspect nail color and marking Inspect shape of nails COMMON NAIL DISORDERS Beau’s Lines Transverse depression in nails indicating temporary disturbance of nail growth (nails grow over for several months) Causes : Acute illness Systemic illness such as severe infection or nail injury Koilonychia / Spoon Nails Concave curvature of the nails Causes : Iron-deficiency anemia Syphilis Use of strong detergents Clubbing Early clubbing ( degrees) Late clubbing (> degrees) Change in angle between nails and nail base; nail bed softening, with nail flattening often Causes : Chronic lack of oxygen due to heart or any pulmonary disease Pitting Pit formation on the nails Causes : Psoriasis Splinter Hemorrhages Red or brown linear streaks in nail bed Causes : Minor trauma Subacute Bacterial Endocarditis Trichinosis Paronychia Inflammation of the skin at the base of the nail Causes : Local infection Trauma
PALPATION
Palpate the nail to assess texture Palpate to assess the texture and consistency, noting whether nail plate is attached to the nail bed Test capillary refill in nail beds by pressing the nail tip briefly and watching for color change LIFESPAN CONSIDERATIONS Infants and Children Newborn skin is covered with vernix caseosa Infants have skin that is thin, soft, and free of terminal hair Milia and “stork bites” are common, harmless marking in newborns Infants may be born with lanugo present Temperature regulation is inefficient in infants (^) Mongolian spots Gray, blue, or purple spots in the sacral and buttocks area (^) Fades by age 3 The Pregnant Female Skin pigmentation increases Areolae, nipples, vulva, perianal area Development of melasma and the linea nigra are common Hormonal changes may cause oil and sweat glands to become hyperactive Worsening acne in the first trimester Hair may fall out during months 1- The Older Adult Skin elasticity decreases with aging (^) Ssecum production decreases and causes dryness Perspiration decreases (^) Decrease in melanin production resulting in graying hair Increased sensitivity to sunlight Nails tend to become thicker and more brittle PSYCHOSOCIAL CONSIDERATIONS Stress induced illness Trichotillomania Hair twisting or plucking Nail biting Visible skin disorders in relation to self- esteem/body image
CULTURAL AND ENVIRONMENTAL
CONSIDERATIONS
Socioeconomic status Home Environment Mean do femployment Changes in skin color may be more difficult to detect in patients with dark skin Dry skin does not necessarily indicate dehydration DOCUMENTATION OF FINDINGS Sample Objective Data: Skin is pink, warm, dry and elastic (+) freckles across the nose and cheeks (-) lesions or excoriations (+) old appendectomy scar @ the RLQ, 4 in. Long, thin, and white (^) With brown hair of shoulder length, clean and shiny With evenly distributed hair along the scalp and perineum Nails form 160-degree angle at base, hard, smooth, and immobile Fingernails well manicured with clear enamel Toenails clean and well trimmed (+) pink nail beds without clubbing (+) smooth cuticles (-) nail plate detachment With good capillary refill @ 2 secs APPROPRIATE NURSING DIAGNOSES Wellness Diagnoses Readiness for enhanced skin, hair, and nail integrity related to healthy hygiene and skin care practices, avoidance of overexposure to sun Health-seeking behavior: requests for information on skin reactions and effects of using sun-tanning lotion Risk Diagnoses Risk for impaired skin integrity related to excessive exposure to cleaning solutions and chemicals Risk for impaired skin integrity related to prolonged sun exposure Risk for imbalanced body temperature related to immobility, decreased production of natural oils, and thinning skin Risk for impaired skin integrity of toes related to thickened, dried toenails
