14 Skin, hair, and nails Be sure to

wear gloves
during your
examination of
the skin, hair,

Assessment and nails.

and palpation.
o assess the skin, hair, and nails, use inspection

Skin
Observe the skin's overall appearance. Then inspect
and palpate the skin area by area, focusing on color,
moisture, texture, tuurgor, and temperatuure.

Color
Look for localized areas of bruising,
cyanosis, pallor, and erythema. Check
for
uniformityof color and hypopig-
mented or hyperpigmented areas.

Detecting color variations in dark-skinned people

Cyanosis Edema Erythema Jaundice Pallor Petechiae Rashes
Examine the Examine the Palpate the Examine the Examine the Examine Palpate the
conjunctivae, area for area for sclerae and Sclerae, areas of area for skin
palms, soles, decreased warmth. hard palate
buccal mu- color and
conjunctivae, lighter pig- texture
in natural, buccal mu
cosa, and palpate for mentation changes.
not fluores cOsa, lips,
tongue. Look tightness. Such as the
for dull, dark
cent, light if tongue, nail abdomen.
color. possible. beds, palms, Look for tiny,
Look for a and soles. purplish red
yellow color. Look for an
dots
ashen color.

Moisture
Observe the skin's
The skin should be moisture content.
a minimal relatively dry, with
amount of
perspiration.
 Assessment 15

Texture and turgor To assess skin turgor in an

infant, grasp a fold of loosely
Inspect and palpate the skin's texture, noting its thick- adherent abdominal skin
ness and mobility. It should look smooth and be between your thumb and
intact.
forefinger and pull the skin
taut. Then release the skin.
The skin should quickly returm
best picture to its normal position. f the
skin remains tented, the
infant has poor turgor.
Assessing skin
turgor in an adult
Gently squeeze the skin on the forearm or sternal
area between your thumb and forefinger, as shown.

If the skin quickly returns to its original shape, the patient has Normal skin
normal turgor. If it returns to its original shape slowly over 30
variations
seconds or maintains a tented position, as shown, the skin has
You may see normal variations in the
poor turgor.
skin's texture and pigmentation.
Such variations may include nevi, or
moles, and freckles (shown below).

Temperature
Palpate the skin bilaterally for temperature
using the dorsal surface of your hands and
fingers. The dorsal surface is the most sensi-
ive to temperature changes. Warm skin sug-
gests normal circulation; cool skin, a possible
underlying disorder.
 16 Skin, hair, and nails

I know you'll
have these
Hair assessment
skills nailed in
When assessing the hair, note the distribution, quantity, no time!
texture, and color. Hair should be evenly distributed.

Nails
Examine the nails for color, shape, thickness, consis-
teney, and contour. Nail color is pink in light-skinned
people and brown in dark-skinned people. The nail
surface should be sightly curved or flat and the edges
smooth and rounded.

Skin abnormMalities5
Lesions
When evaluating a lesion, you'll need to Lesion shapes
classify it as primary (new) or secondary
(a change in a primary lesion). Then deter-
mine if it's solid or fluid-filled and describe
its characteristics, pattern, location, and
distribution. Include a description of sym-
metry, borders, color, configuration, diam-
eter, and drainage. Discoid Annular Target (bull's eye)
Round or oval Circular with central Annular with central
clearing internal activity
Lesion distribution
Generalized- Distributed all
over the body Lesion configurations
Regionalized - Limited to one
area of the body
Localized-Sharply limited to a
specific area
Scattered- Dispersed either
densely or widely
Exposed areas Limited to
areas exposed to the air or sun
Discrete Grouped Confluent Dermatomal
form a line
Intertriginous Limited to Individual lesions Lesions are clus- Lesions merge so
Lesions
fok
areas where skin comes in arch and
are separate and tered together. that discrete lesions or an
low a dermatome.

contact with itself distinct. are not visible or

palpable.
 Skin abnormalities 17

outside the norm

Types of skin lesions

Pustule Cyst Nodule Wheal Fissure

A small, pus-filled le-
sion (called a follicular
pustule if it contains a
hair)
A raised, reddish area A painful, cracklike le-
A closed sac in or un- A raised lesion de-
that's commonly itchy sion of the skin that
der the skin that con tectable by touch
tains fluid or semisolid that's usually 1 cm or and lasts 24 hours or extends at least into
material more in diameter less the dermis

take note

Ulcer
Documenting
Bulla Macule a skin lesion
A large, fluid-filled blis- A small, discolored A craterlike lesion of
ter that's usually 1 cm spot or patch on the the skin that usually
blade
or more in diameter skin extends at least into c/o vight
shoulder

the dermis A+ 0820, pt.

4/15/0%
084S
0-10
scale. A closed,
on a
4/10
Pain, PPer
noted in vight
lesion
Purulent
of back, apprOx
Scapular vegion
Surounding
with3
cm

1.5 cmx l c,

erythema,
T l00.2° F.Call
of
a t O830.
avea

service
Tolin's
to Dr.
placed Angela Kessler, RN

Vesicle Papule
A small, fluid-filled blis A solid, raised lesion
ter that's
usually 1 cm that's usually less than
or less in
diameter 1 cm in diameter
 18 Skin, hair, and nails

cancerous lesions
Benign versus
nevus, or mole
Lesions a y be benign, such a s a benign
However, changes in an existing
growth on the skin
heal could
or a new
that ulcerates o r doesn't
growth
lesion.
indicate cancer or a precancerous

outside the norm

Benign nevus
Types of
skin cancer

Note the
differences
between benign and
cancerous lesions.
1
#

Precancerous actinic keratosis

Symmetrical, round, or oval shape
Sharply defined borders
Uniform, usually tan or brown color
Less than 6 mm in diameter
Flat or raised

Abnormal changes in keratinocytes

Can become squamous cell carcinoma

Dysplastic nevus

Abnormal growth of melanocytes in a mo0e

Can become malignant melanoma

 If you suspect a
lesion may be
malignant melanoma,
observe for these
characteristics.

Basal cell carcinoma

memory
board

Most common skin cancer

ABCDEs of
Usually spreads only locally
Malignant
Squamous cell carcinoma melanoma
A-Asymmetrical lesion

=Border irregular

Begins as a firm, red nodule or scaly, rusted, flat

lesion C= Color of lesion varies with
Can spread if not treated
shades of tan, brown, or black
and, possibly, red, blue, or white
Malignant melanoma

V= Diameter greater than 6 mm

C Elevated orenlarging lesion

existing mole
Can arise on normal skin or from an

If not treated promptly, can spread to other areas

of skin, lymph nodes, or internal organs

 nails
20 Skin, hair, and

Common skin disorders

outside the norm

Psoriasis
Psoriasis is a chronic
disease of marked
epidermal thickening.
Plaques are symmetri
cal and generally ap-
pear as red bases
topped with silvery
scales. The lesions,
which may connect
Contact dermatitis with one another, oc-
Contact dermatitis is Cur most commonly
an inflammatory disor on the scalp, elbows,
der that results from and knees.
contact with an irritant
Primary lesions include
vesicles, large oozing
bullae, and red mac-
ules that appear at lo-
calized areas of red-
ness. These lesions
may itch and burn.

Urticaria (hives)
Occurring as an aller-
gic reaction, urticaria
appears suddenly as
pink, edematous
papules or wheals
(round elevations of
the skin). Itching is in-
tense. The lesions
may become large
and contain vesicles.
 Skin abnormalities 21

Herpes zoster
Herpes zoster ap-
pears as a group of
vesicles or crusted le- P
sions along a nerve
root. The vesicles are

Scabies usually urnilateral and

appear mostly on the
be
Mites, which can
trunk. These lesions
in-
picked up from
an
cause pain but not a
fested person, burrow
rash.
under the skin and
cause scabies lesions.

The lesions appear in

a straight or zigzag-

ging line about s"

(1 cm) long with a

black dot at the end.

Commonly seen be-
elbow and knee,
tween thefingers, at the bend of the
or perineal area, scabies
and around the groin, abdomen,
cause a rash.
lesions itch and may

Once I burrow
under the skin, I Tinea corporis (ringworm)
settle down and Tinea corporis is char
make myself acterized by round,
Comfortable.
red, scaly lesions that
are accompanied by
intense itching. These
lesions have slightly
raised, red borders
vesi
consisting of tiny
cles. Individual rings
to formm
may connect
patches with scal-

loped edges. They uSually

areas of the body.
appear on exposed
 nails
22 Skin, hair, and

outside the norm

Pressure ulcers
localized areas of Staging pressure ulcers
Pressure ulcers are
as a result
skin breakdown that occur gained from your as-
characteristics
Necrotic tissue You can use pressure ulcer
of prolonged pressure. ulcer, as described here. Staa.
vascular supply sessment to stage the pressure
develops because the anatomic depth of exposed tissue. Keep in mind
diminished. ing reflects the
to the area is contains necrotic fissue, you won't be able to
that if the wound
until you can see the wound base.
determine the stage
l e a r n thee
Welcome hithen and
u l c e r stages.
of
pressure To blanch, or not to
As Shakespeare knew,
blanch: that is the
all the world's a stage...
question. The first sign
of a pre9Sure ulcer is a
reddened area of
Reddened area- Stage intact skin that
blanches not. In those
with dark skin, warmth,
-Epidermis edema, discoloration,
induration, or hardness
-Dermis you may Spot.

Subcutaneous tissue

Muscle

Bone

Reddened area Stage l

Double, double, Blister-
toil and trouble.
Marked by partial- -Epidemis
thickness skin loss
involving the
-Dermis
epidermis, dermis,
or both is stage ll.
-Subcutaneous tissue
And superficial
though the ulcer be,
an abrasion, a -Muscle
blister, or a shallow
crater you may see. Bone
 Skin a

Now is the winter

of our discontent.
In
Stage lll ulcer is
stage ll, the
a full-thickness
wound that appears
-Epidermis like a deep crater

when inspected.
-Dermis Underlying fasciae it
and
may extend to
thou might find
Subcutaneous tissue
undermining of thes
-Muscle tissue thats
Connected.

Bone

That it should comne

to thisl As through the
skin the ulcer extends,
damage to muscle,
Stage IV
bone, and supporting
structures accompanies
necrosis of tissues.
Alas, undermining and
-Epidermis
sinus tracts may also
be issues. -Dermis

-Subcutaneous tissue

Muscle

-Bone

Parting is such
s w e e t sorroW,
that J shall say
"Go forth and provide
good wound care
for all morrows!"
 24 Skin, hair, and nails

Hair abnormalities Now "hair" this:

Hair abnormalities
may be caused
by
certain drugs or
Typically stemming from other problems, hair abnormalities can cause patients
emotional distress. Among the most common hair abnormalities are alopecia endocrine
and hirsutism. problems.

outside the norm

Alopecia
Alopecia occurs more
commonly and exten-
sively in men than in
women. Diffuse hair
loss, though common
M
ya normal part of
aging, may occur as a
result of pyrogenic
infections, chemical
trauma, ingestion of Hirsutism
certain drugs, and
Excessive hairiness in
endocrinopathy and
women, or hirsutism,
other disorders. Tinea
can develop on the
capitis, trauma, and full-thickrness
body and face, affect-
burns can cause patchy hair loss.
ing the patient's self-
image. Localized hir-
sutism may occur on
Pigmented nevi. Gen-
ralized hirsutism can
result from certain
drug therapy or from
Such endocrine prob-
lems as Cushing's syndrome,
polycystic ovary syndrome, and acromegaly.
 Nail abnormalities 25

Nail abnormalities
Lala 1oh many nail abnormalities are
alities include clubbed fingers, harmless, some point to
splinter hemorrhages ofserious underlying
the nail bed, and problems.
Nail
Terry's nails.

outside the norm

Splinter hemorrhages
Splinter hemorrhages
are reddish brown nar-
Clubbed fingers row streaks under the
Clubbed fingers can nails. They run in the
result from chronic tis-
Normal fingers same direction as nail

Sue hypoxia. Normally,

Normal angle growth and are
the angle between the
(160 degrees)- caused by minor trau-
fingernail and the point ma. They can also oc
Cur in patients with
where the nail enters
the skin is about 160
bacterial endocarditis.
degrees. Clubbing oc-
Curs when that angle
increases to 180 de-
grees or more. Clubbed fingers
Angle greater than
180 degrees-
Terry's nails
Terry's nails are char-
acterized by trans-
verse bands of white
that cover the nail, ex-
cept for a narrow zone
at the distal end.
Enlarged and curved nail- They're associated
with aging and chronic
disorders, such as cir-
rhosis, heart failure,
and type 2 diabetes.