Skin Assessment and Conditions

Integumentary System Assessment: Skin, Hair, and Nails

• A lecture for BSN211 Clinical Health Assessment - Theory.
• The focus is on integumentary system assessments of the skin, hair, and nails.
• The lectures is for the academic year 2024/2025, week 3.

Learning Objectives

• The student will be able to review the structure and function of the skin, nails, and hair.
• The student will be able to obtain subjective data related to the integumentary system.
• The student will be able to discuss objective data collection of skin, hair, and nails.

Structure of the Skin

• The skin consists of the epidermis, dermis, and subcutaneous layer.
• Epidermis includes the stratum corneum and stratum basale.
• Dermis includes the dermal papilla.
• Other structures: hair shaft, sweat gland pore, sweat, capillary, basement membrane, tactile corpuscle, sebaceous gland, arrector pili muscle, sweat gland duct, lamellated corpuscle, hair follicle, nerve cell process, adipose tissue, blood vessels, and muscle layer.

Functions of the Skin

• Protection against external factors.
• Prevention of penetration by harmful substances.
• Temperature regulation.
• Identification via unique skin markings.
• Communication through sensory perception.
• Wound repair, also known as wound healing.
• Absorption and excretion.
• Production of Vitamin D, which increases calcium absorption.

Subjective Data: Previous History of Skin Disease

• Inquire about a patient’s history of skin diseases or problems.
• Treatment methods are relevant.
• Family history of allergies or allergic skin problems is important.
• Known allergies to drugs, plants, or animals should be documented.
• Note any birthmarks or tattoos.

Subjective Data: Changes in Pigmentation

• Hypopigmentation involves a loss of pigmentation known as "Vitiligo".
• Hyperpigmentation involves an increase in color.
• Generalized changes could mean systemic illness, such as pallor, jaundice, or cyanosis.

Subjective Data: Moles, Dryness, Itching, and Medications

• Any changes in a mole’s color, size, or shape should be noted.
• Note any excessive dryness or moisture.
• Seborrhea presents as oily skin.
• Xerosis presents as dry skin.
• Note any pruritus, which equates to itching.
• Note any medications the patient is taking.

Nursing Diagnosis Example

• Disturbed body image related to changes in pigmentation is evidenced by the patient's expression of concern or discomfort.

Objective Data: Color (Inspection)

• Benign pigmentation includes freckles, moles, and birthmarks.
• Observe the patient's general pigmentation.
• Note widespread color changes i.e., pallor, erythema, cyanosis, and jaundice.
• Transient or expected color changes may indicate a pathology.

Pallor - White Skin

• Pallor is a color change presenting as white skin.
• Pallor involves the loss of redness from oxygenated hemoglobin.
• With pallor, skin color is replaced with collagen (connective tissue).
• Pallor can be a sign of anxiety, fear, or stress.
• Pallor can be a sign of anemia.
• Dark skinned people that experince pallor appear gray (lips, mucous membranes, nails).
• Check the conjunctiva and nail beds when assessing for anemia.

Nursing Diagnosis Example

• Impaired tissue perfusion related to decreased blood flow and oxygenation can be evidenced by pallor.

Erythema: Red Skin

• Erythema is a color change presenting as red skin.
• Erythema is caused by excess blood (hyperemia) in dilated superficial capillaries.
• Erythema is often associated with fever, local inflammation, and emotional reactions.
• Erythema can cause blushing in the neck, cheeks, and upper chest.
• More blood to vessels will increase temperature.
• With dark skinned people that experince Erythema, palpate skin for warmth, tightly pulled skin.

Nursing Diagnosis Example

• Disturbed skin integrity related to inflammation and increased blood flow can be evidenced by erythema.

Cyanosis: Bluish Skin

• Cyanosis is a color change presenting as bluish skin.
• Cyanosis signifies decreased perfusion, indicating reduced oxygenation.
• Cyanosis is seen in lips, nose, cheeks, ears, and oral mucous membranes.
• Cyanosis occurs with hypovolemic shock, heart, and respiratory problems.
• Cyanosis is difficult to observe within dark-skinned individuals.
• Changes in the level of consciousness and respiratory distress indicates clinical signs of hypovolemic shock.

Nursing Diagnosis Example

• Impaired gas exchange related to decreased oxygen saturation can be evidenced by cyanosis.

Jaundice: Yellow Skin

• Jaundice is a color change presenting as yellow skin.
• Jaundice increased amounts of bilirubin in the blood.
• It is first noted in the junction of the hard and soft palate in the mouth and in the sclera, then is visible throughout the entire body.
• Jaundice can occur with hepatitis, cirrhosis, sickle cell anemia, and transfusion reactions.

Nursing Diagnosis Example

• Impaired bilirubin metabolism related to hepatic dysfunction is as evidenced by clinical presentation and laboratory findings.

External Variables Influencing Skin Color

• Fear and anger can cause peripheral vasoconstriction, misleadingly resulting as false pallor
• Embarrassment can cause flushing, resulting as false Erythema
• A hot room can cause vasodilation, leading to false erythema
• A chilly or air-conditioned room can cause vasoconstriction, leading to false pallor and coolness.
• Cigarette smoking can cause vasoconstriction, leading to false pallor.
• Physical attributes like Prolonged elevation can cause decreased arterial perfusion, leading to Pallor and coolness
• Physical attributes like Dependent position can cause venous pooling cause, leading to Redness, warmth, distended veins
• Physical attributes like Immobilization and prolonged inactivity can cause slowed circulation, leading to Pallor, coolness, pale nail beds, prolonged capillary filling time

Vascularity or Bruising

• The nurses should Document Bruises, Needle marks, and Tattoos
• Multiple bruises above the knees or elbows are concerning for possible physical abuse
• A bruise’s color indicates how old it is
• Red = immediately after trauma.
• Blue to purple.
• Blue to green.
• Yellow.
• Brown to disappearing.

Temperature: Palpation

• Note their own temperature and use the dorsa (back of the hand) to palpate the patients.
• Hypothermia: Generalized coolness indicates shock and surgery.
• Localized coolness in peripheral arterial insufficiency indicates a limb in a cast or IV infusion.
• Hyperthermia: Generalized warmth with increased metabolic rate suggests a fever.
• Localized heat suggests infection or trauma.

Moisture: Palpation

• Observe skin for changes in moisture and palpate.
• Diaphoresis indicates profuse perspiration with an increased metabolic rate during heavy activity or fever.
• Dehydration presents as dry skin and mucous membranes, as well as cracked lips and fissures.

Texture and Thickness: Palpation

• Observe skin for smoothness and even surfaces.
• Observe for thickened skin
• Callus: circumscribed overgrowth of the epidermis adapted to excessive pressure, causing weight bearing and friction.

Edema: Palpation

• Edema is fluid accumulation in intercellular spaces.
• To detect edema, imprint your thumbs firmly against the patient's ankle, malleolus, or tibia.
• Non-pitting edema presents with no dent or mark after applying thumb pressure.
• Pitting edema presents if pressure leaves a dent (hollow).
• 1+ = mild = slight indentation
• 2+ = moderate = subsides rapidly
• 3+ = deep = lasts for a short time
• 4+ = very deep = lasts for a long time

Mobility and Turgor: Palpation

• Mobility is the skin's ease of rising.
• Turgor is the skin’s ability to return to place, aka elasticity.
• To assess, pinch up a large fold of skin on the anterior chest under the clavicle.
• Poor mobility: Scleroderma, also known as "hard Skin" occurs in edema.
• Poor turgor: Dehydration, weight loss. The skin “stands” by itself.

Lesions

• These are traumatic or pathological changes in previously normal skin structures.
• Equipment: Gloves and a magnifier glass.
• Inspect and palpate, wearing gloves, to assess the depth and temperature.
• Scrape gently and assess the surrounding skin (redness).
• Tenderness: Patient feels pain when the site is touched.

Describing Skin Lesions

• Color.
• Elevation: flat or raised.
• Location and distribution: localized or generalized.
• Size: Use a ruler and measure in cm.
• Pattern or shape: Configuration in relation to each other.
• Exudate: Note color and or odor of the fluid that comes out of the wound.
• Primary lesions: develop on unaltered skin, and present upon onset of disease.
• Secondary lesions: change overtime due to disease progression, treatment, or manipulation.

Lesions: ABCDE

• ABCDE is a mnemonic used to summarize the characteristics of pigmented lesions
• A: Asymmetry
• B: Border irregularity
• C: Color variation
• D: Diameter greater than 6mm
• E: Elevation or Enlargement
• Any rapidly changing lesions, a new pigmented lesions, development of itching, burning, or bleeding of the mole should raise suspicion of malignant melanoma

Classification of Skin Lesions According to Configuration

• Annular/circular: Begins in the center and spreads to the periphery.
• Linear: Arranged as a scratch, streak, or line.
• Confluent: Lesions run together (e.g., urticaria [hives]).
• Discrete: Individual lesions remain separate.
• Zosteriform: Linear arrangement along a unilateral nerve route (e.g., herpes zoster).
• Grouped: Clusters of lesions (e.g., vesicles of contact dermatitis)

Objective Data: Primary Skin Lesions Types (Refer to table 12-4)

• Macule: only a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, measles, and scarlet fever.
• Patch: macules larger than 1 cm. Examples: Mongolian spot, vitiligo, and measles rash.
• Papule: Something you can feel (solid, elevated, circumscribed, diameter of less than 1 cm) caused by superficial thickening in the epidermis. Examples include elevated nevus (mole) and wart (verruca).
• Nodule: Solid, elevated, hard, or soft, larger than 1 cm. May extend deeper into the dermis than a papule. Examples: xanthoma, fibroma, and intradermal nevi.
• Wheal: Superficial, raised, and transient with a slightly irregular shape; is also erythematous. Examples: mosquito bites and allergic reactions.
• Urticaria (Hives): Wheals come together, forming extensive reaction. Intensely pruritic.
• Cyst: Encapsulated fluid-filled cavity in the dermis or subcutaneous layer that tensely elevates skin. Examples: sebaceous cysts and wens.

Objective Data: Secondary Skin Lesions

• These occur from a change in primary lesions from the passage of time; an evolutionary change.
• Note: Combinations of primary and secondary lesions may coexist in the same person.
• Crust: The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on fluid ingredients (blood, serum, or pus). Examples: impetigo, weeping eczematous dermatitis, and scabs.
• Fissure: a linear crack with abrupt edges that extends into the dermis; can be dry or moist. Example: cheilosis.
• Erosion: Scooped out with a shallow depression. It is superficial; the epidermis is lost and moist, but has no bleeding. Heals without a scar because the erosion does not extend into the dermis.
• Ulcer: Deeper depressions extending into the dermis with an irregular shape. They may bleed and leave a scar when healed. Examples: stasis ulcer and pressure injury.
• Scar: After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This presents a permanent fibrotic change. Examples include surgical sites and acne.

Braden Scale for Pressure Ulcer Assessment

• The tool was developed in 1984 by Braden and Bergstrom.
• It has six elements that contribute to either a higher intensity and duration of pressure or a lower tissue tolerance to pressure, increasing the risk for pressure ulcer development.
• The lower the score, the greater the risk.
• 15 + = low risk
• 13-14 = moderate risk
• 12 or less = high risk
• Below 9 = severe risk

Nursing Diagnosis Examples

• Risk for infection related to open skin lesions and immunosuppression.
• Impaired skin integrity related to external factors, altered tissue perfusion, and inadequate nutrition can be as evidenced by skin assessment.

Skin Self Examination Steps

• Undress completely.
• Check the forearms, palms, and space between fingers.
• Turn over hands and study the backs.
• Face a mirror and bend the arms at the elbow.
• Face a mirror and study the entire front of the body.
• Start at the face, neck, and torso while working down to lower legs.
• Pivot to face the right side into the mirror.
• Study the sides of upper arms while working towards the ankles
• Repeat with the left side
• Face the back to the mirror, study the buttocks, thighs, and lower legs.
• Use the handheld mirror to study upper back
• Use the handheld mirror to study scalp while lifting the hair. A cool setting blow dryer will help.
• Sit on chair or bed. Study insides of each leg and soles of feet. The small mirror will help.

Hair Assessment: Subjective Data

• Ask about any recent hair loss, if it happened suddenly or slowly and associated with fever, illness, or stress?
• Ask about any unusual hair growth?
• Ask about any recent changes in hair texture and if the changes correlated with life events (pregnancy)?
• Alopecia: Occurs from male pattern balding, chemotherapy, injury, infection, and is an abnormal finding.
• Hirsutism: Excessive facial hair in women is an abnormal finding
• Pediculosis: Head and pubic lice is an abnormal finding.

Hair Assessment: Objective Data

• Inspect and palpate the hair and scalp for changes to the hair.
• Color: Depends on melanin production.
• Increased melanin production presents as black to light blonde hair.
• Reduced melanin production presents gray hair.
• Texture: Fine, thick, straight, curly, or kinky.
• Distribution: Conforms to normal male and female pattern (all over body and in genital area).
• Lesions: Separate the hair and lift it; if itching is reported, observe the scalp for seborrhea (dandruff).

Nail Assessment: Subjective Data

• Ask about any changes in nail color, consistency (uniformity), and shape?
• Ask about self-care practices and footwear.
• Inspect and palpate the nail surface and nail folds, as well nail edges and the nail base (angle of nail base)

Nail Assessment: Objective Data

• In shape adn Contour: nail surface is normally slightly curved, the angle of nail base is 160deg.
• Abnormal findings for shape and contour include rounded, and enlarged nail base are the findings for clubbing. Note that: "Nail base angle exceeds 180 degrees (convex shape) . May indicate chronic hypoxia." Nail edges should be smooth, rounded and clean.
• Borders are approximated, skin is without erythema, edema, and exudate. Note is also to be given to dirty nails, bitten nails, traumatized.
• Consistency: Surface is smooth and regular, not-brittle. Nail thickness is uniform: Nails adheres to nail bed, base is firm on palpation. Ridges are transverse grooves/lines may indicate a nutrient deficiency.
• Nail bed pink and even in reference to nail Color. Dark skinned - brown black pigmented areas and White linear marking - accidental injury/abnormal marking.

Toenail Assessment: Objective Data

• Separate toenails and note smooth skin in between.

Nail Assessment: Objective Data: Capillary Refill

• Indicates the status of peripheral circulation, ie., vascularity.
• Note, Press is applied to nail bed until it turns white to observe capillary refill
• Depress the nail edge blanch, and release.
• Note if the return color is instant or delayed more than 2 seconds.
• Sluggish Color returns Takes more then 2 seconds indicates cardiovascular, respiratory dysfunction, anemia, or cold environment.
• Cyanotic nail beds are an abnormal finding indicating cardiovascular or respiratory dysfunction.

Nursing Diagnosis Example

• Ineffective tissue perfusion related to low hemoglobin as is evidenced by a capillary refill greater than 3 seconds.