NUR631 - Skin and Appendages PDF

EVALUATION OF THE SKIN AND APPENDAGES NUR 631 Advanced Health Assessment Jason Kiszka DNP, FNP-BC, APRN Integumentary System The skin is the heaviest single organ of the body accounting for aprox 16% of body weight. Composed of three layers: epidermis, derm...

EVALUATION OF THE SKIN AND APPENDAGES NUR 631 Advanced Health Assessment Jason Kiszka DNP, FNP-BC, APRN Integumentary System The skin is the heaviest single organ of the body accounting for aprox 16% of body weight. Composed of three layers: epidermis, dermis and the subcutaneous tissues. Hair, nails, sebaceous and sweat glands are appendages of the skin. Functions of the Skin Major function is to keep the body in homeostasis. Provides protection from microorganisms, harmful substances & radiation Thermoregulation Maintains fluid balance Immunity Absorption Excretion Synthesis of Vitamin D Sensation/communication with the external environment Anatomy and Physiology The skin is composed of 3 layers: 1. epidermis 2. dermis 3. subcutaneous tissue Epidermis Most superficial layer of skin Thin avascular, relies on the underlying vascularized dermis for nutrition Composed of stratified squamous epithelium (flat, dead cells filled with keratin, helps make our skin waterproof) Composed of two layers: stratum corneum & stratum basale/stratum spinosum  Dermis 2nd layer, made up of richly vascularized connective tissue Contains blood vessels, hair follicles and sensory nerves Supports and separates the epidermis from the subcutaneous layer Dermal blood nourishes the epidermis Merges with adipose Subcutaneous tissue Hypodermis Composed of loose connective tissue filled with subcutaneous (adipose cells, fatty cells) Functions: 1. connects the dermis to underlying organs 2. generates heat and provides insulation 3. protective cushion 4. provides (reserve for) calories  Skin Color Depends on the amount & type of melanin (brownish pigment, genetically determined and increases with exposure to sun) Also influenced by: Vascular structures Changing hemodynamics (ex pallor due to anemia, cyanosis due to hypoxia) Changes in carotene & bilirubin  Hair Adults have two types of hair: Vellus hair (short, fine, inconspicuous and unpigmented) Terminal hair (coarser, thicker, pigmented) Scalp hair and eyebrows are terminal hair  Nails Protect the ends of the fingers Base of the nail is the nail plate The nail plate gets its pink color from the vascularized nail bed which it is attached to The white half moon is the lunula Cuticle functions as a protective seal Lateral nail folds cover the sides of the nail plate Fingernails grow approx 0.1mm daily (toenails grow slower) Cross section of the fingertip  Pilosebaceous & Sweat Glands Pilosebaceous Sweat glands Oil glands that secrete a Two types eccrine & fatty substance onto the apocrine skin surface through hair Eccrine: widely follicles distributed, open directly On all skin surfaces to the skin, help control except palms & soles temperature Apocrine: in axilla and genital regions, open into hair follicles, bacterial decomposition responsible for adult body odor. The Health History Common or concerning symptoms - Hair loss & nail changes - Rash & pruritis - Lesions or moles Ask the patient: - “Have you noticed any changes is your skin or your hair?” - “Have you noticed any moles that have changed in size, shape, color, or sensation?” - “Have you noticed any new moles?” What additional questions would you consider??????? Obtaining the history continued… HPI and Associated Symptoms How long? Does it itch? Where did it start? Have you traveled? Is it painful? How did it look initially? Has there been drainage, Was it localized? crusting? New pets in the home? Did it spread? Does it spare the palms and Any sick contacts? soles? Hx of STD? What have you used at home to treat the rash? Evaluation of the Patient with a Dermatologic Complaint: Health History Past history of skin related disorders? If so what was it? Allergies? If so what was the reaction? Medications (immunosuppressive medications?) Family history –atopic Associated symptoms (fever, chills, nausea or vomiting) Past medical history (immunocompromised patient? Previous drug therapy Occupation (chemical exposure?) Social history (time in wooded areas?) Effect of the disease on the patient? Patient’s opinion? Inspection of the Skin Examine the whole patient Offer a chaperone if indicated Be orderly and complete (compare corresponding areas) Inspection Palpation (checking texture, firmness or induration) Examine for signs of systemic illness Educate the patient as you go Use appropriate descriptive terminology  Key components of full body exam "Patient Position—Seated Patient Position—Standing Inspect the hair and scalp Inspect the lower back. (distribution, texture, and Inspect the posterior thighs quantity). and legs. Inspect the head and neck, Inspect the breasts, axillae, including forehead, eyebrows, eyelids, eyelashes, conjunctivae, and genitalia including sclerae, nose, ears, cheeks, lips, axillary and pubic hair. oral cavity, chin, and beard. Alternative positioning is Inspect the upper back. having the patient supine Inspect the shoulders, arms, and then prone. The systematic hands including palpation of flow of examination is from fingernails. head to foot anteriorly to Inspect the chest and abdomen. posteriorly Inspect the anterior thighs and legs. Palpation of the Skin Temperature Turgor Texture Moisture Surface characteristics of any lesion (crusting, scaling) Disorders of the Skin, Hair, and Nails During direct examination of the the skin your will note: Morphology –structure Distribution - location Configuration - shape Extent of disease Remember lesions are solidary areas of altered skin (may be single or multiple); while a rash is a widespread eruption of lesions.  Describing skin lesions Important to use specific terminology to describe skin lesions & rashes Good descriptions should include: number, size, color, shape, texture, primary lesion, & configuration Primary skin lesions are those that develop as a direct result of a disease process (vesicular rash 2/2 HSV) Secondary skin lesions are lesions that result from modification or evolution of the primary lesion (ex scratching a mole and causing bleeding/crusting) Distribution Localized Generalized Random or patterned, symmetric or asymmetric Particular body parts are affected (eg, palms or soles, scalp, mucosal membranes) Trunk Extremities Face involved? On sun-exposed or protected skin Morphology –Lesion Type Macules – flat, non palpable, usually < 1 cm in diameter (freckles, flat moles) Patch- circumscribed flat area of change in color >1cm Papules – elevated, usually < 1 cm in diameter that can be palpated (warts, acne, skin cancers) Morphology –Lesion Type Plaques – palpable, > 1 cm in diameter, either elevated or depressed (psoriasis) Nodules - are firm papules or lesions that extend into the dermis or subcutaneous tissue, >1cm (cyst or lipoma) Morphology – Lesion Type (cont.) Vesicles - small, clear, fluid-filled blisters < 1 cm in diameter (contact dermatitis, HSV) Bullae are clear fluid-filled blisters > 1 cm in diameter Pustules are vesicles that contain purulent fluid common in bacterial infection or folliculitis  Morphology – Lesion Type (cont.) Scale is heaped-up accumulations of horny epithelium (flakey) Urticaria (wheals or hives) elevated lesions caused by localized edema. Wheals are pruritic and red. Urticaria (wheal, hives) Morphology – Lesion Type (cont.) Crusts (scabs) consist of dried serum, blood, or pus Erosions are open areas of skin that result from loss of part or all of the epidermis Fissures linear cleft into the dermis or epidermis Morphology – Lesion Type (cont.) Ulcers result from loss of the epidermis and at least part of the dermis Petechiae are nonblanchable punctate foci of hemorrhage Purpura is a larger area of hemorrhage that may be palpable Morphology – Lesion Type (cont.) Atrophy is thinning of the skin, which may appear dry and wrinkled, resembling cigarette paper. Scars are areas of fibrosis that replace normal skin after injury Telangiectases are foci of small, permanently dilated blood vessels Telangiectasi a Configuration Annular Discrete - separate Confluent - running together Linear take on the shape of a straight line Nummul Annular lesions are rings with central ar clearing Nummular lesions are circular or coin-shaped Target (bull’s-eye or iris) lesions appear Target (bull’s as rings with central duskiness eye)  Configuration (cont.) Serpiginous lesions have linear, branched, and curving elements Reticulated lesions have a lacy or networked pattern. Serpigino Herpetiform grouped papules or vesicles us arranged like those of a herpes simplex infection. Zosteriform describes lesions clustered in a dermatomal distribution similar to herpes zoster. Zosteriform  Texture Verrucous lesions have an irregular, pebbly, or rough surface. Lichenification is thickening of the skin with accentuation of normal skin markings Texture (cont.) Induration is deep thickening of the skin Umbilicated lesion has a central indentation and are usually viral Xanthomas usually yellowish or waxy lesions Xanthomatosi s  Evaluation of the patient with hair complaints Determine the overall pattern of hair loss or thinning Inspect scalp for erythema, scaling, pustules, tenderness, bogginess or scarring Look at the width of the hair part in various sections of the scalp History should include duration of symptoms, increased shedding, pattern of hair loss, medication hx, hair care practices, associated medical conditions, & stressors Decrease in hair density is usually caused by male or female pattern hair loss but less commonly by Inspection of Hair Color Quantity Distribution Condition of the Scalp Lesions or pediculosis Hair Loss Affects half of men by 50 yo & half of women by age of 80 yo Types: Non-scarring - Alopecia areata - Male pattern baldness - Female pattern hair loss Scarring: characterized by shiny skin, complete loss of hair follicles and often discoloration. Should be ref to derm for bx. Alopecia Areata Traction Alopecia Disorders of the nails Digital Clubbing Bulbous swelling of the soft tissue at the nail base. Loss of the normal angle between the nail and the proximal nail fold. Clinical sign of: - pulmonary disease - cardiovascular abnormalities - inflammatory bowel diseases - malignancies Paronychia Superficial infection of the proximal and lateral nail folds adjacent to the nail plate. Nail fold is often red, swollen, and tender. Usually caused by staphylococcus aureus or streptococcus species Needs I + D and +/- oral antibiotics Choose broad coverage Common in those who have hands in water often: dishwashers, bartenders, waitresses, people who chew or pick the cuticle If left untreated can create a felon which is a closed space infection.  Onychomycosis Most common cause of nail thickening & subungual debris Affects 1 in 5 over the age of 60 years Best prevention is to treat tinea pedis Most often fungal but should confirm this through a pathologic evaluation of nail clippings before treating with oral antifungals.  Pitting Punctate depressions of the nail plate 2/2 defective layering of the superficial nail plate Associated with psoriasis Can be seen in reactive arthritis, sarcoidosis, alopecia areata, and atopic or chemical dermatitis Common Adult Skin Problems  Follicular Eruptions Acne: the most common cutaneous disorder in the US Disorder of the pilosebaceous unit Proliferation of keratinocytes at the opening of the follicle causing plugging of the follicle Cosmetics, humidity, heavy sweating and stress worsen the condition Treatment based on severity  Rosacea Adults rarely occurs in children Patients have central facial redness, papules, pustules, flushing, telangiectasia, burning edema and dryness Pathogenesis is poorly understood. May be due to immune abnormalities, inflammatory reaction to skin microorganisms, UV exposure, vascular hyperreactivity and genetics. Contact Dermatitis Irritant - more common - poison ivy, oak, sumac - occupational exposures – latex Allergic - occurs suddenly or after many exposures Intertriginous - areas where skin directly opposes skin Nickel Contact Dermatitis Allergic Contact Dermatitis (Tattoo) Food allergy rash Contact Dermatitis Linear Eruption Poison Ivy (Plant rashes) Dermatitis Eczema Inflammatory reaction of the skin Erythema, edema, papules and crusting of the skin followed, finally, by lichenification and scaling of the skin Flexor surfaces Causes itching and burning of the skin Effects all age groups Treatment: steroids, antibiotics when there is a secondary infection, antihistamines Eczema (Atopic Dermatitis) Psoriasis Inflammatory disease Well-demarcated small pink papules and plaques with silvery-white scales Occur on scalp, extensor surfaces of elbows, knees, intergluteal cleft, areas of trauma Can be itchy, and when the scale is peeled away, small bleeding points may appear (Auspitz’s sign) This condition often waxes and wanes spontaneously Tx.: topical steroids, phototherapy (PUVA) Psoriasis Psoriatic Nails Tinea Fungal skin infection (ringworm) a red ring of small blisters or a red ring of scaly skin that grows outward as the infection spreads Different locations: -capitis -corporis -pedis -unguium (also known as onychomycosis) Tx: with antifungal preparations  Tinea Tinea Corporis  Tinea Tinea Pedis Capitis (Athlete’s Foot) Tinea Unguium (Onchyomycosis) Herpes Zoster Also known as “shingles” Caused by the reactivation of the chicken pox virus 1 in 3 persons will experience in lifetime Begins as a painful sensation (often mistaken for a musculoskeletal injury) 1 – 2 days later red, blistering, unilateral rash will occur Herpes Zoster (Shingles)  Skin tags Skin Tags Soft and fleshy Often involving the neck, axillae or back May have a hint of brown pigmentation Moles  Age or liver spots Occur on sun exposed skin Light brown & uniform in color but may be asymmetric  Pityriasis Rosea: Round to oval scaling plaques on the abd and back Erythematous to skin- colored Acute, self-limiting, most likely due to virus Can use topical corticosteroids for itching Phototherapy for severe presentations Verucca vulgaris (wart) Skin-colored to pink More verrucous than keratotic (rough, scaly) May see hemorrhagic punctate  Seborrheic Keratoses: Can mimic a melanoma if it has an erythematous base Stuck on appearance or flattened ball of wax Verrucous texture May crumble or bleed if picked Darkly pigmented Seborrheic Dermatitis Symmetric erythematous patches Overlying greasy scales Chronic, relapsing Occurs in areas with large amts of sebaceous glands such as the scalp, face, upper trunk and intertriginous areas Mildest & most common form is dandruff Most often treated with topical antifungals Scabies Keloid A hypertrophic scar due to aberrant wound healing Genetic, systemic and local factors contribute to the formation of keloids Indurated, elevated, erythematous lesion with a glossy surface. Red in color in white individuals Hyperpigmented in persons of color  Skin Cancers Skin cancers are the most commonly diagnosed cancers America Lifetime risk estimated about 1 in 5 More than 3 million Americans are diagnosed each year with a nonmelanoma skin cancer and over 91,000 were diagnosed with melanoma in 2018 Melanoma is the fifth most frequently diagnose cancer in men and the six most frequently diagnosed cancer in women  Skin Cancer Nonmelanoma skin cancer is rarely fatal, causing around 2,000 deaths per year Melanoma accounts for 1% of skin cancers it is the most lethal causing an estimated 9,320 deaths in 2018 Sun and UV exposure is the strongest risk factor for developing melanoma The melanoma risk assessment tool developed by National Cancer Institute https://mrisktool.cancer.gov/ Risk factors for melanoma P 301 table 10-3 Basal Carcinomas Nonmelanoma skin cancer (NMSC) Erupts in basal layer (epidermis) Papular or nodular lesions May have raised pearly borders Central ulceration (rodent borders) Squamous Cell Carcinoma (NMSC) Initially thickening with scale Appear in sun-exposed areas Become larger, deeper, ulcerated Melanoma Look like moles, but different from common moles: A – asymmetry B – border irregularity C – color variations (more than 2 colors:brown, blue, tan, black, red) D – diameter > 6 mm E – evolving Please see chart on 304  Skin Cancer Prevention The best defense against skin cancer is to avoid UV radiation which includes limiting time in the sun, using sunscreen, and avoiding indoor tanning especially in childhood through young adults. Help educate your patient on using at least SPF 30, reapplying every two hours after being outdoor or after in water According to USPSTF: patients who have a clinical skin examination within three years prior to melanoma diagnosis have a thinner melanoma then those who had not had an examination. According to the American Cancer Society, there is no screening guidelines for skin cancer but it it recommends regular skin examinations for people with increased risk for skin cancer; including self exams. Monkeypox Symptoms usually start within 3 weeks of exposure to the virus. If someone has flu-like symptoms, they will usually develop a rash 1-4 days later. Rash that may be located on or near the genitals or anus and could be on other areas like the hands, feet, chest, face, or mouth. Monkeypox can be spread from the time symptoms start until the rash has healed. The rash will go through several stages, including scabs, before healing. Lesions are firm or rubbery, well-circumscribed, deep-seated, and often develop umbilication (resembles a dot on the top of the lesion). The incubation period is 3-17 days. During this time, a person does not have symptoms and may feel fine. The illness typically lasts 2-4 weeks.  Monkeypox Other symptoms of monkeypox can include: Fever Chills Swollen lymph nodes Exhaustion Muscle aches and backache Headache Respiratory symptoms (e.g. sore throat, nasal congestion, or cough) You may experience all or only a few symptoms Sometimes, people have flu-like symptoms before the rash. Some people get a rash first, followed by other symptoms. Others only experience a rash. Patients who were exposed to monkeypox should be monitored for 21 days Recording the Physical Examination Use phrases Examples: “Skin warm and dry. Color normal for ethnicity. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymoses.” “Marked facial pallor, with circumoral cyanosis. Palms cold and moist. Cyanosis in nailbeds of fingers and toes. Numerous palpable purpura on lower legs bilaterally.”