UNIVERSITY OF CENTRAL FLORIDA



[pic] School of Nursing

Christopher W. Blackwell, Ph.D., ARNP-C

Assistant Professor, School of Nursing

College of Health & Public Affairs

University of Central Florida

NGR 5003: Advanced Health Assessment & Diagnostic Reasoning

Unit Four: Dermatological, Breasts, & Axillae :

• Basic assessment of the dermatological system, breasts, and axillae

• Advanced assessment of the dermatological system, breasts, and axillae

• Assessment findings of abnormal presentations in the dermatological system, breasts, and axillae

• Differential diagnoses of the dermatological system, breasts, and axillae

• Advanced Clinical reasoning: A case study approach

advanced assessment of skin, hair, and nails

LEARNING OBJECTIVEs

1. Conduct a history related to skin, hair, and nails.

2. Discuss examination techniques for skin, hair, and nails.

3. Identify normal age and condition variations of skin, hair, and nails.

4. Recognize findings that deviate from expected findings.

5. Relate symptoms or clinical findings to common pathologic conditions.

Outline for Chapter 8: Skin, Hair, and Nails

Anatomy and Physiology

• Skin provides an elastic, rugged, self-regenerating, protective covering for the body.

• The skin and its appendages are our primary physical presentation to the world.

• Skin structure and physiologic processes perform the following integral functions:

• Protect against microbial and foreign substance invasion and minor physical trauma

• Retard body fluid loss by providing a mechanical barrier

• Regulate body temperature through radiation, conduction, convection, and evaporation

• Provide sensory perception via free nerve endings and specialized receptors

• Produce vitamin D from precursors in the skin

• Contribute to blood pressure regulation through constriction of skin blood vessels

• Repair surface wounds by exaggerating the normal process of cell replacement

• Excrete sweat, urea, and lactic acid

• Express emotions

Epidermis

• The epidermis, the outermost part of the skin, consists of two major layers:

• The stratum corium provides protection. It is composed of dead squamous cells containing keratin.

• The cellular stratum synthesizes keratin cells.

• The basement membrane, below the cellular stratum, connects the epidermis to the dermis.

• Stratum lucidum is found only in thicker skin of palms and soles.

• The epidermis is avascular and gets nutrition from the dermis.

Dermis

• The dermis is vascular connective tissue. It separates the epidermis from the cutaneous adipose tissue.

• Elastin, collagen, and reticulin fibers provide strength and stability.

• The dermis contains sensory and autonomic motor nerve fibers.

Hypodermis

• The hypodermis consists of connective tissue containing fatty cells. Adipose tissue generates heat and provides insulation and caloric reserve.

Appendages

• Appendages are formed from the epidermis invaginating into the dermis.

• Eccrine sweat glands secrete water and regulate body temperature.

• Apocrine glands are deeper glands that respond to emotional stimuli by secreting odorless white fluid.

• Sebaceous glands secrete sebum as regulated by hormonal levels.

• Hair consists of epidermal cells in the dermal layers. Vellus hair is short, fine, soft, and nonpigmented. Terminal hair is coarser, longer, thicker, and usually pigmented.

• Nails are hard plates of keratin. The pink color is from vascular beds under the plate. The cuticle is stratum corium that covers the nail root. The paronychium is soft tissue surrounding nail border.

Age- and Condition-Related Variations

• Infants and children. The skin of young people is smoother than that of adults and lacks terminal hair. After birth, there is variable desquamation. Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth. Lanugo hair is found on shoulders and back. It is shed in about 2 weeks after birth. Head hair is shed by 2 to 3 months and is replaced by more permanent hair. Eccrine sweat glands function after the first month of life. Inactive apocrine glands make the skin less oily.

• Adolescents. During puberty, the apocrine glands enlarge and become active. Sebaceous glands increase sebum production, which gives an oily appearance and predisposes the individual to acne. Coarse terminal hair appears in axillae and pubic area.

• Pregnant women. During pregnancy, increased blood flow results from peripheral vasodilation and increased capillaries. Sweat and sebaceous gland activity increases. Skin thickens and fat is deposited in subdermal layers. Increased pigmentation occurs from hormonal changes.

• Older adults. With age, sebaceous and sweat gland activity decreases. Epidermis thins and flattens. Vascularity in dermis decreases and becomes less elastic. Cutaneous tissue decreases. Gray hair occurs from a decrease in the number of functioning melanocytes. Density and rate of hair growth decline. Nail growth slows and nails become thicker, brittle, and yellow. They also develop ridges and are prone to split.

Review of Related History

History of Present Illness

• Skin. Patients with skin problems should be asked about changes in skin such as warts, moles, or lesions, as well as temporal sequence, symptoms, and location of any skin occurrence. Associated symptoms and factors, such as high temperature, exposure to drugs, and travel history should be listed. Patient’s response to the problem and any home treatment should be noted. Patient’s perception of the cause of the condition should also be explored.

• Hair. Data relevant to a hair condition include the following: changes in hair patterns, occurrence or recurrence of problem, associated symptoms and factors (e.g., itching or drug exposures), dietary habits, patient’s reaction to the problem, and factors affecting condition.

• Nails. Patients with nail conditions should be asked about the following: any changes in their nails, symptoms (e.g., pain or swelling), temporal sequence of the problem, recent exposures, and things making condition better or worse.

Past Medical History

• Skin. Data relevant to the past medical history include previous skin problems (e.g., skin reactions or lesions), exposure to sunlight, changes in sensory stimuli, and systemic diseases affecting skin.

• Hair. Patients with hair conditions should be questioned about any previous hair problems (e.g., loss of hair), pattern changes, and systemic problems (e.g., thyroid disease).

• Nails. Past medical history should include data on previous nail problems (e.g., infections) and systemic problems (e.g., cardiac conditions) that could influence nail condition.

Family History

• Relevant data include current or past dermatologic diseases of family members, allergic hereditary diseases or skin disorders, and familial hair patterns.

Personal and Social History

• Pertinent data include skin care habits (e.g., cosmetic use and sun exposure), hair care habits (e.g., cleansing routine, as well as the use of any coloring or permanent products), nail care habits, use of medications, exposure to environmental or occupational hazards, and any recent psychologic or physiologic stress.

Age- and Condition-Related Variations

• Infants. Relevant data include feeding and diaper history, types of clothing, products used to wash clothes, bath practices, habits of dressing the infant, and the home environment.

• Children. Explore eating patterns, disease exposure, allergic disorders and reactions, previous skin injury, hair manipulation, and nail-biting habits.

• Pregnant women. Pertinent data include weeks of gestation or postpartum, hygienic practices, presence of prior skin lesions, and effects of pregnancy on previous skin lesions.

• Older adults. Ask older patients about changes in touch sensation, chronic itching, susceptibility to skin infections, changes or slowness in healing, history of falling, diabetes, vascular diseases, or hair loss.

See Risk Factors: Basal and Squamous Cell Carcinoma (p. 214) and Risk Factors: Melanoma (p. 215).

Examination and Findings

|Summary of Examination—Skin, Hair, and Nails |

|Skin |

|Ensure adequate lighting. |

|Assess skin contour, symmetry, color. |

|View exposed and unexposed areas. |

|Describe lesions according to characteristics, exudates, location, and distribution. |

|Use flashlight to see color, elevation, and borders of lesions. |

|Use a Wood’s lamp to detect the presence of fungal infection. |

|Smell skin odors. |

|Feel skin for moisture, temperature, texture, turgor, and mobility. |

|Use dorsal surface of hands and fingers to palpate skin temperature. |

|View cysts and masses. |

|Hair |

|Assess color, distribution, and quantity of hair. |

|Palpate texture. |

|Note any hair loss, inflammation, or scarring. |

|Nails |

|Note nail color, length, configuration, angle at the base, and symmetry. |

|Observe nail folds for signs of infection, warts, cysts, or tumors. |

|Squeeze nail to test adherence. |

Summary of Skin, Hair, and Nail Findings

|Life Cycle |Normal |Typical |Findings Associated |

|Variations |Findings |Variations |with Disorders |

|Adults |Thinnest skin is on eyelids. Thickest|Callused areas are yellow. Skin | |

| |is on soles, palms, and elbows. Color|striae, freckles, birth marks, nevi, | |

| |is uniform, except in sun-exposed |and melasma may be present. | |

| |areas. |Freckling of buccal cavity, gums, and| |

| |Skin temperature is even |tongue is present in some | |

| |Texture is smooth, soft, and even. |dark-skinned persons. | |

| |Skin is resilient. Scalp hair is |Color hues in dark- skinned persons | |

| |shiny, smooth, and resilient. |are best seen in the sclera, mucosa, | |

| |Nail color is a variation of pink. |and nail beds. | |

| |Nail edges are smooth and rounded. |Lips and gums are bluish in | |

| | |dark-skinned persons. | |

|Infants and |Newborn skin may be red. |At birth, generalized lanugo suggests|Newborn skin distortions suggest masses, |

|children |Vernix caseosa is a normal birth |prematurity. |nodules, or tumors. The presence of |

| |covering. |Physiologic jaundice is common. |patches, erythema, scaling, crusts, |

| |Newborn nails may need to be trimmed |Primary irritant or eczematous |fissures, vesicles, lesions, and skin |

| |to prevent scratching. |dermatitis may cause localized |irregularities in children requires |

| | |lesions. |investigation. |

| | |Skin roughness may result from |Localized redness suggests inflammation. |

| | |clothing, coldness, or soap. |Hemorrhage results from injury, steroids, |

| | |Nail shape and opacity vary. |or systemic disorders. Fluid-filled |

| | |Pigment deposits may be present in |lesions show red glow with |

| | |dark-skinned persons. Darkened nails |transillumination. Generalized lesions may|

| | |may result from antimalarial drug |indicate a systemic disorder, allergy, or |

| | |treatment or shoe trauma. |genetic disorder. Annular patterns are |

| | |White spots in nail plate may result |associated with pityriasis rosea, tinea |

| | |from mild trauma. Peeling nails may |corporis and cruris, urticaria. |

| | |occur with water exposure. |Connective tissue diseases lead to changes|

| | |Longitudinal ridging and beading are |in skin mobility. Asymmetric hair loss in |

| | |common. |males may indicate a pathologic condition.|

| | | |Female alopecia or female hirsutism in |

| | | |male hair patterns may indicate pathology.|

| | | |Yellow nails occur with psoriasis, fungal |

| | | |infections, and respiratory disease. |

| | | |Darkened nails can result from Candida |

| | | |infection or hyperbilirubinemia. |

| | | |Green-black nails are caused by |

| | | |Pseudomonas infection or subungual |

| | | |hematoma. Nail depression and clubbing |

| | | |occur from systemic disease. Separation of|

| | | |nail plate from bed results from psoriasis|

| | | |and infections. |

|Adolescents |Adolescents are prone to acne from |Perspiration may result from anxiety |Fine or coarse hair and hair loss may be |

| |hormonal changes. Terminal hair |or obesity. |due to thyroid conditions. |

| |develops at puberty. |Nail hygiene is a clue about | |

| |Body odors develop. |self-care and emotional and social | |

| | |levels. | |

|Pregnant women |During pregnancy, there are |Increased pigmentations occur from | |

| |peripheral vasodilation and increased|hormonal changes. Pregnancy causes | |

| |capillaries. |striae, vascular spiders, and acne in| |

| |Sweat and sebaceous gland activity |some. | |

| |increases. |Vascular spiders and hemangiomas that| |

| |Palmar erythema., a diffuse redness |are present may increase in size. | |

| |that covers the entire palmar surface| | |

| |or the thenar and hypothenar | | |

| |eminence, is a common finding in | | |

| |pregnancy and usually disappears | | |

| |after delivery. | | |

|Older adults |Skin becomes more transparent, pale, |Graying hair occurs as a result of a |Stasis dermatitis and solar keratosis are |

| |dry, wrinkled, and hyperpigmented |decrease in functioning melanocytes. |skin conditions that affect older adults. |

| |with aging. |Balding patterns in men are |Cardiac disease influences nail |

| |Hair becomes coarser with age. |genetically determined. Several types|conditions. |

| |Nails thicken and become more brittle|of lesions may be present: | |

| |with age. |­ Cherry angiomas | |

| | |­ Sebaceous hyperplasia | |

| | |­ Cutaneous tags/horns | |

| | |­ Senile lentigines | |

• See Box 8-1: Patient Instructions for Skin Self-Examination (p. 174).

• See cultural differences discussed in the Physical Variations boxes (pp. 171, 176, 177, 191, 200, and 202) and Box 8-2: Cutaneous Manifestations of Traditional Health Practices (p. 176).

• See the Mnemonics box for melanoma (p. 215).

• See Table 8-1 (p. 177), Table 8-2 (p. 177) and Table 8-3 (p. 178), which describe nevi, moles, and cutaneous color changes.

• See Figure 8-7 (p. 180), Table 8-4 (pp. 183 to 185), Table 8-5 (pp. 186 to 188), and Figure 8-15 (p. 193) for skin lesion and nail drawings.

• See Figures 8-10, 8-11, and 8-12 (p. 190) for various patterns of skin lesions.

• See Box 8-5: Expected Color Changes in the Newborn (p. 195); Risk Factors box: Hyperbilirubinemia in the Newborn (p. 195); Box 8-6: Skin Lesions: External Clues to Internal Problems (p. 196); and Table 8-7: Estimating Dehydration (p. 199).

• See Box 8-7: Staging of Decubitus Ulcers (p. 202).

• See Table 8-6: Morphologic Characteristics of Skin Lesions (p. 189).

Advanced assessment of breasts and axillae

LEARNING OBJECTIVEs

1. Conduct a history related to the breasts and axillae.

2. Discuss examination techniques for the breasts and axillae.

3. Identify normal age and condition variations to the breasts and axillae.

4. Recognize findings that deviate from expected findings.

5. Relate symptoms or clinical findings to common pathologic conditions.

Outline for Chapter 16: Breasts and Axillae

Anatomy and Physiology

• The breasts are paired mammary glands located on the anterior chest wall, superficial to the pectoralis major and serratus anterior muscles. In women, the breast extends from the second or third rib to the sixth or seventh rib, and from the sternal margin to the midaxillary line. The nipple is located in the center, surrounded by the areola.

• The female breast is composed of glandular and fibrous tissue (which provides support for the breast) and fat (subcutaneous and retromammary) in proportions that vary with age, genetic predisposition, nutritional status, and pregnancy.

• The glandular tissue of the breast is arranged into lobes, each composed of lobules of milk-producing acini cells that empty into lactiferous ducts during lactation.

• Vascular supply to the breast is primarily through branches of the internal mammary and the lateral thoracic artery.

• For purposes of examination, the breast is divided into five segments: four quadrants and the tail of Spence.

• Contraction of the circular and longitudinal muscles in the nipple, induced by tactile, sensory, or autonomic stimuli, causes the milk ducts to empty. Nipple erection is supported by venous stasis in the erectile vascular tissue. Nipples range in color from pink to black.

• Each breast contains a lymphatic network (pectoral, subscapular, central, and brachial) that drains the breast radially and deeply.

Age- and Condition-Related Variations

• Childhood and preadolescence. Childhood and preadolescence represent a latent phase of breast development when some branching of the primary ducts occurs. Tanner’s five stages of developing sexual maturity in temporal relationship to menarche are useful in assessing breast development. Thelarche (breast development) represents an early sign of puberty in adolescent girls. Breasts develop at different rates, which can result in asymmetry.

• Pregnant women. During pregnancy, breasts become soft, loose, and enlarged. They develop darker, wider areolae with Montgomery tubercles. Breasts exhibit a visible network of veins. Colostrum, containing antibodies and other host resistant factors, is produced.

• Lactating women. Engorgement is caused by tissue edema and the filling of alveoli and lactiferous ducts. Two to 4 days after delivery, high-protein milk replaces colostrum. By the tenth day, protein decreases and lactose increases; this stabilizes by 1 month. After termination of lactation, breast size decreases, but seldom to prelactation size.

• Menopausal and older adults. A moderate decrease in glandular tissue and decomposition of alveolar and lobular tissue occurs before menopause. After menopause, glandular tissue atrophies and is replaced by fat. In older adults, the inframammary ridge thickens, suspensory ligaments loosen, and nipples become smaller, flatter, and less erectile. Skin may become thin and dry, and axillary hair may decrease.

Review of Related History

History of Present Illness

• Patients with a breast or axilla problem should be asked to describe discomfort, temporal sequence, relationship to menses, characteristics, nipple retractions, masses and discharges, relationship to external irritants, and enlargement or tenderness in the lymph nodes.

• Breast discomfort/pain. Assess temporal sequence, relationship to menses, character (e.g., pulling, burning, drawing, stabbing, aching, throbbing), any associated symptoms or contributory factors, and medications taken.

• Breast mass or lump. Assess temporal sequence, relationship to menses, symptoms such as tenderness or pain, changes in lump, any associated symptoms, and medications taken.

• Nipple discharge. Assess character, any associated symptoms, associated factors, and medications taken.

Past Medical History

• Pertinent data include previous breast diseases, diagnostic tests, surgeries and treatment, menstrual history, pregnancy and breast-feeding history, risk factors for both benign breast disease and breast cancer risks, and the past use of hormonal and other medications.

Family History

• Family history should include occurrence of breast cancer or other breast disease in any relative (male or female). Data should be specific as to age at occurrence, treatment, and results.

Personal and Social History

• Relevant data include age, cyclic and noncyclic changes in breast characteristics, menstrual or menopausal status, use of breast support, caffeine intake, alcohol intake, breast self-examination, self-care, use of hormonal medications, and risk factors for cancer.

Age- and Condition-Related Variations

• Pregnant women. Ask patient about sensations in the breast (fullness, tingling, tenderness), use of a supportive brassiere, and plans for breast-feeding.

• Lactating women. Data specific to lactating women include self-care habits, nursing routines, associated problems, cultural beliefs, diet, and medications.

• Older adults. Relevant data include occurrence and treatment of skin irritation and the use of postmenopausal hormone therapy.

See Risk Factors: Breast Cancer (p. 497).

Examination and Findings

|Summary of Examination—Breasts and Axillae |

|Breasts |

|Inspection |

|Examine breasts for size, symmetry, contour, skin color and texture, venous patterns, and lesions. |

|Use several positions for inspection: |

|Seated, arms hanging loosely at sides |

|Seated, arms extended over head |

|Seated, hands pressed against hips |

|Seated, hands pressed together |

|Leaning forward from the waist |

|Nipples |

|Inspection |

|Examine nipples for symmetry, direction, contour, color, and texture. |

|Mnemonics: Five Ds Related to Nipples |

|Breasts and Axillae |

|Palpation |

|Palpate breasts and axillae with patient in sitting position with arms hanging freely at sides. |

|Use finger pads and push toward chest in systematic pattern. Use light and then heavier pressure without lifting fingers. |

|Palpate the tail of Spence in each breast, gently compressing the tissue between your thumb and fingers. |

|Continue palpation with the patient in the supine position. Have her raise one arm behind her head and place a small pillow or |

|folded towel under the shoulder. |

|Gently compress the nipple and massage around the areolae. |

|Use palmar finger surfaces to palpate into the axillary hollow for lymph nodes. |

Summary of Breasts and Axillae Findings

|Life Cycle |Normal |Typical |Findings Associated |

|Variations |Findings |Variations |with Disorders |

|Adults |Breasts are nearly equal in size|Benign, soft, mobile, |Carcinoma is suspected when there is peau |

| |and bilaterally convex. |fluid-filled, bilateral cysts |d’orange color from blocked lymph drainage; |

| |Breasts have equal smoothness, |(fibrocystic) may be present. |nipple inversion, retractions or dimpling; |

| |contour, and pigmentation. |In some males, breast tissue may|thickened skin and enlarged pores; unilateral|

| |Slight venous markings are |be smooth, firm, and mobile |inversion; and unilateral venous patterns and|

| |bilateral, and nipples and |(adult gynecomastia). |nipple discharge. |

| |areolae are bilaterally equal. |Breast sizes vary. |Red, scaling, crusty patch on nipples suggest|

| |Breasts are nontender and |Breast pairs may also vary in |ductal cancer. |

| |nonsuppurative. |size. |Bilateral firm, rubbery, mobile masses |

| |Montgomery tubercles are normal.|Striae may be visible. Healthy, |(fibroadenoma) may suggest malignancy. Tumors|

| |Breast tissue is dense, firm, |large skin pores may resemble |of subareolar ducts (papillomas) are |

| |and elastic. |pores seen with malignancy. |suggestive of malignancy. Hard, fixed, |

| | |Usual skin markings and nevi may|single, stonelike mass suggests malignancy. |

| | |be present. | |

|Infants and |At birth, breasts may be |Supernumerary nipples may look |Female prepubertal breast enlargement |

|Children |enlarged from maternal estrogen.|like moles. Both nipples may be |(premature menarche) may be present. |

| |Newborns may also have a milky |bilaterally inverted. | |

| |nipple discharge. |Montgomery tubercles may be | |

| | |present. | |

|Adolescents |Breasts of female adolescents |Breasts develop at different |Boys’ breasts may be enlarged (gynecomastia).|

| |may be asymmetric. |rates, which can result in | |

| | |increased temporary asymmetry. | |

| | |During menstrual cycle, there | |

| | |may be increased nodularity and | |

| | |tenderness. | |

|Pregnant women |Pregnancy causes breast |After termination of lactation, |Particularly during lactation, breasts may |

| |tingling, tenderness, and size |breast size decreases but seldom|become swollen, inflamed, and infected |

| |increase. |to prelactation size. |(mastitis). |

| |Nipples enlarge and colostrum |Spider veins may occur on the | |

| |appears. Venous networks from |upper chest. | |

| |obesity or pregnancy may be | | |

| |present. | | |

| |Breasts are more nodular during | | |

| |pregnancy. After delivery, | | |

| |breasts may be hard, warm, | | |

| |reddened, and shiny (engorged). | | |

| |Breasts are less firm and | | |

| |nipples are darker after | | |

| |lactation. | | |

|Older adults |Some premenopausal decrease in |Breasts of postmenopausal women |Menopausal women may experience blocked |

| |glandular alveolar and lobular |may be flatter, longer, and more|subareolar ducts (mammary duct ectasia). |

| |tissue occurs. |relaxed from chest wall. |Firm, discolored, irregular mass can result |

| |After menopause, glandular |Breasts of older women are more |from fat necrosis in response to local |

| |tissue atrophies and is replaced|fine and granular. |injury. |

| |by fat. | | |

• See Box 16-1: Breast Self-Examination (pp. 498 and 499); Box 16-2: Screening for Breast Cancer (p. 500); and Box 16-4: Examining the Patient Who Has Had a Mastectomy (p. 511).

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc

Course Lecture Content:

Dermatological System; Breasts and Axillae:

• Advanced assessment of the dermatological system, breasts, and axillae

• Assessment findings of abnormal presentations in the

dermatological system, breasts, and axillae

• Differential diagnoses of the dermatological system,

breasts, and axillae

Christopher W. Blackwell, Ph.D., ARNP-C

Assistant Professor, School of Nursing

College of Health & Public Affairs

University of Central Florida

NGR 5003: Advanced Health Assessment & Diagnostic Reasoning

• Advanced Assessment of Dermatological System

• Anatomy and Physiology:

• Skin protects against infection and invasion/ minor trauma

• Retard body fluid loss through mechanical barrier

• Regulate body temp though radiation, conduction, convection, and evaporation

• Sensory perception via nerve endings

• Produce vitamin D

• Help regulate BP through constriction of skin blood vessels

• Repair surface skin wounds

• Excrete sweat, urea, and lactic acid

• Express emotions

• Epidermis:

• Outermost layer, consists of stratum corneum and cellular stratum

• Connects to the dermis via the basement membrane

• Dermis:

• Vascular connective tissue layer supporting and separating epidermis from SQ adipose

• Sensation of pain, temperature, and touch received in dermis

• Hypodermis:

• SQ layer, rich with connective tissue and adipose cells

• Appendages:

• Eccrine sweat glands, spocrine sweat glands, sebaceous glands

• Vellus and terminal hair

• Nails: eponychium, nail bed, nail plate, paronychium, lunula, cuticle

• Advanced Assessment of Dermatological System

• Infants and Children:

• Skin smoother due to absence of terminal hair and exposure

• Vernix caseosa covers the child at birth

• SQ layer undeveloped, leading to potential hypothermia

• Newborn covered with fine silky hair called lanugo (shed within 10-14 days after birth); eccrine glands function within a month (no apocrine function)

• Adolescents:

• Apocrine glands enlarge and become active

• Androgen stimulates sebum production, increasing oily skin and acne

• Pregnant Women:

• Blood flow increases to skin from inc. in # of capillaries and vasodilation (spider hemangiomas/ telegenctasia); sebaceous gland activity inc.; fragility of tissues increases due to elastin (separation); pigment increases on face, nipples, areolas, vulva, perianal skin, and umbilicus

• Older Adults:

• Sebaceous/sweat gland activity decreases (xerosis)

• Dermis becomes less elastic, losing collagen and elastic fibers

• Wrinkling increases due to lifelong sun exposure

• Functioning melanocytes decrease, graying the hair

• Terminal hair begins to soften to vellus, vellus coarsens to terminal

• Advanced Assessment of Dermatological System

• Anatomic Structure of the Skin

• Advanced Assessment of Dermatological System

• Review of Related Hx:

• Hx of Present Illness:

• Skin:

• Changes in dryness, pruritus, sores, rashes, lumps, discolorations, changes in lesions, non-healing areas

• Temporal sequence: date of onset (sudden/gradual), time sequence of occurrence/development, date of recurrence

• Location: skinfolds, extensor/flexor surfaces, local/general

• Associated Symptoms: presence of systemic disease, fever, sweats, chills, stress/leisure activity

• Recent exposure to drugs, environmental/occupational toxins, others w/ skin conditions

• Patient’s perception of cause

• Travel Hx: where, when, length of stay, exposure to environment/people/diseases

• Self-treatment, response, aggravating/alleviating factors

• Affects on ADL, self-concept, etc.

• Rx: topical or systemic; nonRx/Rx

• Hair:

• Changes in loss, growth, distribution, texture, color

• Occurrence: sudden/gradual, symmetric vs. asymmetric patterns, recurrent

• Associated symptoms: pain, itching, lesions, systemic diseases, fever, physiologic/ psychological stress

• Exposure to Rx, environmental/occupational chemicals, commercial hair care products

• Nutrition: Lipid deficiency; dietary changes/dieting

• Self-treatment, response, aggravating/alleviating factors

• Affects on self-concept, etc.

• Rx: Rx/Non-Rx; hair loss Tx (Propecia, Minoxidil, etc.)

• Advanced Assessment of Dermatological System

• Nails:

• Changes: splitting, breaking, discoloration, ridging, thickening, markings, separation from nail bed

• Recent Hx: systemic illnesses/fever, trauma, psych/physiologic stress

• Associated pain, edema, exudate

• Temporal: sudden or gradual onset, relationship to injury of nail/finger

• Recent exposure to Rx, environmental/occupationa; chemicals, frequent immersion in water

• Self-treatment, response, aggravating/alleviating factors

• Rx: Rx/NonRx

• Past Medical Hx:

• Skin: Previous conditions/problems, allergic reactions (describe lesion), Tx; tolerance to sunlight, diminshed/heightened sensitivity to stimuli; cardiac, respiratory, hepatic, endocrine, or other systemic diseases

• Hair: Previous problems, loss, thinning, usual growth/distribution, brittleness, breakage, Tx; systemic problems (thyroid/hepatic disorder, severe illness, malnutrition, skin disorder)

• Nails: Previous problems/injury (bacteria/fungi/virus); systemic problems (associated skin disorder, congenital anomalies, respiratory, cardiac, endocrine, hematologic, or other systemic disease

• Advanced Assessment of Dermatological System

• Family Hx: Current/past dermatological diseases, melanoma/CA, pruritus, allergies, bacterial/fungi/viral infections; hereditary allergic diseases (asthma/hay fever); familial loss or hair coloration patterns

• Personal and Social Hx:

• Self-care: soaps, oils, lotions, cosmetics, home remedies/preparations, sun exposure/protection patterns, recent changes in self-care

• Assess monthly performance of SSE (8-1)

• Hair care habits: cleaning routine, shampoos/rinses used, coloring preparations, perms, recent changes in care

• Nail care habits: difficulty in clipping nails; instruments used; biting

• Exposure to environment/occupation toxins (dyes, chemicals, plants, toxins, frequent immersion of hands in water, sun exposure)

• Psych/physiologic stress; Use of ETOH; Smoking/recreational drugs

• Infants:

• Feeding Hx (breat/bottle, type of formula, what/when foods introduced

• Diaper Hx: type of diaper used, skin cleaning routines, use of rubber pants, washable diapers (how cleaned)

• Types of clothing and washing practices (soap, detergents, new blanket/clothing)

• Bath practices (soaps, oils, lotions)

• Dress Habits: amount and type of clothing related to environmental temp

• Temp and humidity of home environment (AC/heat/humidification)

• Rubbing head against mattress, rug, furniture, wall

• Advanced Assessment of Dermatological System

• Children:

• Eating habits: food allergens; chocolate, candy, soft drinks, bubble gum

• Allergies: eczema, urticaria, pruritus, hay fever, asthma, chronic resp. disorders

• Pet/animal exposure; outdoor exposures from playing, hiking, camping, picnics

• Skin injury Hx: frequency of falls, cuts, abrasions, unexplained injuries

• Chronic manipulation of hair/nail biting

• Pregnant Women:

• Weeks of gestation/postpartum

• Hygiene practices; exposure to irritants; presence of skin problems before pregnancy (acne tends to worsen)

• Effects of pregnancy on preexisting conditions: psoriasis may remit; condylomata acuminata become longer and more numerous

• Older Adults:

• Increased/decreased sensation to touch/environment

• Generalized chronic pruritus: exposure to skin irritants, detergents, lotions (w/ high ETOH content), woolen clothing, humidity of environment

• Susceptibility to skin infectionsl healing responsesl frequent falls resulting in hematomas/ cuts/abrasions

• Hx of DM or PVD; hair loss Hx (gradual vs. sudden; symmetric vs. asymmetric loss pattern)

• Advanced Assessment of Dermatological System

• Examination and Findings:

• Skin:

• Inspection:

• Adequate lighting is essential; daylight best for color detecting

• Examine the entire body: assess distribution and extent of lesions, symmetry of body surfaces, detect different body areas, and compare sun-exposed to non-sun-exposed areas

• Remove all clothing (provide privacy); pay careful attention to intertriginous surfaces, especially in bed-riddin and older clients

• Assess for presence of lesions, color and uniform thickness, symmetry, hygiene

• Skin thinnest on eyelids, thickest soles, elbows, and palms; not callusing on hands and feet

• Darker skin expected around knees and elbows

• Nevi present in everyone; differing locations; may be flat, slightly raised, dome-shaped, smooth, rough, or hairy (tan, gray, shades of brown-to-black); Most harmless—may be dysplastic, pre/cancerous

• Cancerous nevi appear on the upper back in men and legs in women

• Cholama (mask) on face common in pregnancy

• Color- hues in dark persons best seen in sclera, conjunctiva, buccal mucosa, tongue, nail beds, and palms

• Hyperpigmented macules normal on soles of feet; freckling normal in buccal mucosa, gums, and tongue; slight bluish color to lips/gums normal in dark-skinned; muddy sclera

• Abnormal Dermatological Presentations

• Pathological Vascular Skin Lesions

• Advanced Assessment of Dermatological System

• Palpation:

• Palpate for moisture, temperature, texture, turgor, and mobility

• Dampest areas on the scalp, forehead, and axillae

• Assess intertriginous areas carefully for cutaneous candidiasis

• Skin should be cool-to-warm to touch; texture smooth, soft and even; widespread roughness may be kyperkeratosis, also occurs from arsenic/toxin exposure

• Skin should return to baseline < 2 sec for turgor (assess clavicle)

• Skin Lesions:

• Lesions are primary (spontaneous) or secondary (result from trauma to a lesion)

• Describe lesions (size, shape, color, texture, elevation/depression, pedunculation) according to exudate (color, odor, amt., consistency); configuration (annular, grouped, linear, arciform, diffuse), and location/distribution (generalized/localized, region of the body, patterns of discreetness or confluent)

• Measure lesions precisely (ht/width/depth—in cm); no household item comparisons

• 5-10 power lamp helpful for detailed lesion inspection

• Transillumination helpful to examine fluid in cysts/masses

• Wood’s lamp useful to distinguish fluorescing lesions (fungus)

• Abnormal Dermatological Presentations

• Primary Skin Lesions

• Macule: Flat, circumscribed

• area at color change; 180o (Schamroth technique), associated with resp/CV disease, cirrhosis, cellulitis, thyroid disease (feels boggy)

• Nail plate should feel hard and smooth w/ uniform thickness; nail separation from bed common in psoriasis, trauma, candidal, or Pseudomonas infection

• Advanced Assessment of Dermatological System

• Schamroth Technique

• Abnormal Dermatological Presentations

• Pathological Nail Presentations

• Advanced Assessment of Dermatological System

• Infants and Children:

• First few hours of life, newborn is red

• Physiologic jaundice mildly present in up to 50%; should subside in 3-4 weeks

• If jaundice extends below nipples, bilirubin excessively high

• Assess newborn carefully over spine, midline of head, nape of neck to bride of nose, and neck to ear (sinus tracts; clefts; cysts)

• The older the baby, the more simian creases (Down’s Syndrome)

• Transient puffiness in hands, feet, eyelids, legs, pubis, sacrum normal in some newborns; disappears in 2-3 days

• Cyanosis of the hands and feet present at birth through several days; if persists, suspect cardiac disease

• Mongolian spots (normal) occur in dark-skinned; bluish-black-to-gray; disappear in preschool years

• Milia common during 1st 2-3 months (clogged sebaceous glands)

• Sebaceous hyperplasia (tiny yellow macules/papules) common forehead, cheeks, nose, and chin; disappear at 1-2 months

• Best to assess turgor by pinching skin on ABD; excessive dryness/moisture rarely significant in children

• Dennie-Morgan fold common flap of skin above eye, results from chronic rubbing

• Advanced Assessment of Dermatological System

• Adolescents: Same exam as an adult; hair and skin oiliness normal; address concerns about acne

• Pregnant Women: Striae gravidarum normal to occur ABD, thighs, and breasts; fade but never disappear; telangiectasias on face; most epidermal tags resolve; linea nigra; cholasma in 70%; pruritus w/o rash over ABD and breasts common; hair loss w/ shedding 2-4 months after delivery common; acne inc. in 1st trimester, declines by 3rd

• Older Adults: Normally transparent and paler in light-skinned individuals w/ inc. freckling; flaking and scaling on EXTs, turgor not reliable for hydration; assess for breakdown at heels, sacrum, elbows, scapulae, occiput; wrinkling and small areas of purpura normal; cherry angiomas, seborrheic keraotosis, sebaceous hyperplasia, cutaneous tags/horns, senile lentigines all normal

• Abnormal Dermatological Presentations

• Corn: Results from friction forces thickening of skin; common in

interdigital spaces of toes

• Callus: Superficial area of hyperkeratosis

• Eczematous Dermatitis: Most common inflammatory disorder; acute, subacute, chronic

• Abnormal Dermatological Presentations

• Furuncle: Small perifollicular pustular nodule (staph)

• Folliculitis: Staph infection of hair follicle; small pustules

• Abnormal Dermatological Presentations

• Cellulitis: Diffuse, acute, strept/staph infection; red, hot, tender, indurated streaking

• Tinea: Fungal infection, typically angular (corporis, cruris, capitis, pedis, unguim)

• Abnormal Dermatological Presentations

• Pityriasis Rosea: Primary oval or round plaque with superficial scaling on EXT/trunk; parallel alignment w/ ribs

• Psoriasis: Well-circumscribed, dry, silvery, scaling papules and plaques

• Abnormal Dermatological Presentations

• Rosacea: Telangiectasia, erythema, papules, and pustules on central face

• Drug Eruptions: Discrete/confluent erythematous maculopapules on trunk, face, EXT, palms, and soles

• Abnormal Dermatological Presentations

• Herpes Zoster: Varicella infection; single dermatome consisting of red, swollen plaques, vesicles become filled w/ purulent fluid

• Herpes Simplex: Grouped, painful erosions/ulcer; forms crust (type 1 oral; type 2 genital)

• Abnormal Dermatological Presentations

• Basal Cell Carcinoma: Most common; race, ears, neck, scalp, shoulders, and back

• Abnormal Dermatological Presentations

• Squamous Cell Carcinoma: Malignant tumor arising from epidermis; scalp, back of hands, lip* and ear*; base could be inflammed

• *- Most vulnerable areas

• Abnormal Dermatological Presentations

• Malignant Melanoma: Develops from melanocytes

• ABCDE Rule: Asymmetry; Borders; Color; Diameter; Elevation

• Abnormal Dermatological Presentations

• Kaposi Sarcoma: Malignant tumor of the endothelium: soft, bluish-purple, painless; immunocompromise (HIV)

• Abnormal Dermatological Presentations

• Alopecia Areata: Sudden, rapid onset of hair loss (shaft poorly developed and breaks)

• Traction/Scarring Alopecia

• Abnormal Dermatological Presentations

• Paronychia: Redness, swelling, and tenderness at lateral nail folds

• Tinea Unguium: Yellow, hardening of nail due to fungus

• Ingrown Nails: Nail pierces nail fold and grows into dermis

• Subungal Hematoma: Blood collects under the nail plate until nail grows out.

• Leukonychia Punctata: White spotting under the nail (from injury)

• Habit-tic Deformity: Horizontal sharp grooving in band extending to tip of nail

• Onycholysis: Loosening of the nail plate with separation from bed

• Koilonychia (spooning): Fe-deficiency, anemia, syphillis, fungal infection causes concavity of nail

• Beau Lines: Coronary occlusion, hypercalcemia, or dkin disease causes sharp lateral lines in nail

• Terry Nails: Cirrhosis and hypoalbuminemia causes transerve white band over nails

• Psoriasis: Pitting, onycholysis, and subungual thickening

• Warts: Epidermal neoplasms cause by virus

• Digital Mucous Cysts: Groove in nail plate w/ jelly-like filled cysts at tip

• Abnormal Dermatological Presentations

• Pregnant Women:

• PUPP

• Herpes

• Infants and Children:

• Café-Au Lait Patches: > 5 patches w/ diameter > 1cm in children ................
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