THE INTEGUMENTARY SYSTEM

 The skin covers the internal structures of the body and protects them from
the external world
 Along with hair and nails, the skin provides a window for viewing changes
taking place inside the body
 As a nurse, you observe a patient’s skin, hair, and nails regularly, so it’s
likely that you would be the first to detect abnormalities
 Your sharp assessment skills will help supply a reliable picture of the
patient’s overall health

 To perform an accurate physical assessment, you’ll need to understand the

anatomy and physiology of the skin, hair, and nails

 Also called the INTEGUMENTARY SYSTEM, the skin is the body’s largest
organ and has several important functions, including
o Protecting the tissues from trauma and bacteria
o Preventing the loss of water and electrolytes from the body
o Sensing temperature, pain, touch, and pressure
o Regulating body temperature through sweat production and
evaporation
o Synthesize vitamin D
o Promoting wound repair by allowing cell replacement of surface
wounds

Layers of the Skin:

 The skin consists of two distinct layers:
o Epidermis
o Dermis
 Subcutaneous tissues lies beneath these layers
 The epidermis – the outer layer – is made of squamous epithelial tissue
o It’s thin and contains no blood vessels
  The two major layers of the EPIDERMIS are:
o the stratum corneum – the most superficial layer
 the deeper basal cell layer, or stratum germinativum. The stratum corneum
is made up of cells that form in the basal cell layer, then migrate to the
skin’s outer surface, and die as they reach the surface
 However, because epidermal regeneration is continuous, new cells are
constantly being produced
 The basal cell layer contains melanocytes, which produce melanin and are
responsible for skin color
 Hormones, the environment, and heredity influence melanocyte
production
 Because melanocyte production is greater in some people than in others,
skin color varies considerably

 The DERMIS – the thick, deeper layer of the skin – consists of connective
tissue and an extracellular material called MATRIX, which contributes to the
skin’s strength and pliability
 Blood vessels, lymphatic vessels, nerves, and hair follicles are located in
the dermis, as are sweat and sebaceous glands
 Because it’s well supplied with blood, the dermis delivers nutrition to the
epidermis
 In addition, wound healing and infection control take place in the dermis

 SEBACEOUS GLANDS, found primarily in the skin of the scalp, face, upper
body, and genital region, are part of the same structure that contains the
hair follicles
 Their main function is to produce sebum, which is secreted onto the skin or
into the hair follicle to make the hair shiny and pliant
 There are two types of sweat glands:
o The eccrine glands, which are located over most of the body, produce
a watery fluid that helps regulate body temperature
o Apocrine glands secrete a milky substance and open into the hair
follicle. They’re located mainly in the axilla and the genital areas

Effects of Aging on Skin and Glands:

 As people age, skin functions decline and normal changes occur
  As a result, elderly patients are more prone to skin disease, infection,
problems with wound healing, and tissue atrophy
 Glands also change with age; sweat glands become fibrotic and produce
less sweat
 This drop in sweat volume decreases the body’s ability to cool, increasing
the risk for hyperthermia

How Skin Ages

Change Findings in elderly people
Pigmentation Pale color
Thickness Wrinkling, especially on the face, arms, and legs
Parchment like appearance, especially over bony prominences and on the
dorsal surfaces of the hands, feet, arms, and legs
Moisture Dry, flaky, and rough
Turgor “tents” and stands alone, especially if the patient is dehydrated
Texture Numerous creases and lines

 Hair is formed from keratin and produced by matrix cells in the dermal
layer
 Each hair lies in a hair follicle and receives nourishment from a papilla, a
loop of capillaries at the base of the follicle
 At the lower end of the hair shaft is the hair bulb
 The hair bulb contains melanocytes, which determine hair color
 Each hair is attached at the base to a smooth muscle called the arrector pili
o This muscle contracts during emotional stress or exposure to cold
and elevates the hair, causing goose bumps.
 A neonates’s skin is covered with lanugo, a fine, downy growth of hair
 Lanugo can be located over the entire body but occurs mostly on the
shoulders and back
 Most of the lanugo is shed within 2 weeks of birth
 The amount of hair on the neonate’s head varies, and all of the original hair
is lost several weeks after birth
 It slowly grows back, sometimes in a different color
  As a person ages, melanocyte function declines, producing light or gray
hair, and the hair follicle itself becomes drier as sebaceous gland function
decreases
 Hair growth declines, so the amount of body hair decreases
 Balding, which is genetically determined in younger individuals, occurs in
many peoples as a normal result of aging

 Nails are formed when epidermal cells are converted into hard plates of
keratin
 The nails are made up of the nail root (or nail matrix), nail plate, nail bed,
lunula, nail folds, and cuticle
 The nail plate is the visible, hardened layer that covers the fingernails
 The plate is clear with fine longitudinal ridges
 The pink color results from blood vessels underlying vascular epithelial cells

 The nail matrix is the site of nail growth

 It’s protected by the cuticle
 At the end of the matrix is the white, crescent-shaped are, the lunula,
which extends beyond the cuticle

 With age, nail growth slows and the nails become brittle and thin
 Longitudinal ridges in the nail plate become much more pronounced,
making the nails prone to splitting
 Also, the nails lose their luster and become yellowed

 When assessing a problem related to skin, hair, or nails, you need to

thoroughly explore the patient’s chief complaint, medical history, family
history, psychological history, and patterns of daily living

ASKING ABOUT THE SKIN:

 Most complaints about the skin involve itching, rashes, lesions,
pigmentation abnormalities, or changes in existing lesions
  Typical questions to ask about changes in a patient’s skin include:
o How and when did the skin changes occur?
o Are the changes in the form of a skin rash or lesion?
o Is the change confined to one area, or has the condition spread?
o Does the area bleed or have drainage?
o Does the area itch?
o How much time do you spend in the sun, and how do you protect
your skin from ultraviolet rays?
o Do you have allergies?
o Do you have a family history of skin cancer or other significant
diseases?
o Do you have a fever or joint pain, or have you lost weight?
o Have you had a recent insect bite?
o Do you take any drugs or herbal preparations? If so, which ones?
o What changes in your skin have you observed in the past few years?
o What skin products do you use?
o Have you recently changes or added new soaps, detergents, or dryer
sheets?

Additional History Questions for Infants and Children:

 Remember to ask the parents these questions when obtaining a history for infants
and children
 Does the child have any birthmarks?

 When the child was a newborn, did he experience any change in skin color –
for example, cyanosis or jaundice?
 Have you noted any rashes, burns, or bruises? If so, where and when, and
what was the cause?
 Has the child been exposed to any contagious skin conditions – such as
scabies, lice, or impetigo – or communicable diseases?

ASKING ABOUT THE HAIR:

 Most concerns about the hair refer either to hair loss or hirsutism, an
increased growth and distribution of body hair
  Either of these problems can be caused by such factors as skin infections,
ovarian or adrenal tumors, increases stress, or systemic diseases, such as
hypothyroidism and malignancies

 To identify the cause of your patient’s hair problem, ask:

o When did you first notice the loss (or gain) of hair? Was it sudden or
gradual?
o Did the change occur in just a few spots or all over your body?
o What was happening in your life when the problem started?
o Do you take any medications or herbal preparations? If so, which
ones?
o Are you experiencing itching, pain, discharge, fever, or weight loss?
o What serious illness, if any, have you had?
o Have you ever had hair replacements?
o Have you ever experienced hair loss? (or gain) before?
o Do you use hair dye? How often?

ASKING ABOUT THE NAILS:

 Most complaints about the nails concern changes in growth or color
 Either of these problems may result from infection, nutritional deficiencies,
systemic illnesses, or stress

 Typical questions to ask about changes in a patient’s nails include:

o When did you first notice the changes in your nails?
o What types of changes have you noticed (for example, nail shape,
color, or brittleness?)
o Were the changes sudden or gradual?
o Do you have other signs or symptoms, such as bleeding, pain,
itching, or discharge?
o What’s the normal condition of your nails?
o Do you have a history of serious illness?
o Do you have a history of nail problems?
o Do you bite your nails?
o Have you had nails tips attached?
  To assess skin, hair and nails, you’ll use the techniques of inspection and
palpation
 Before beginning the examination, make sure the room is well lit and
comfortably warm
 Wear gloves during your examination

 Before you begin your skin assessment, gather these items:

o A clear ruler with centimeter and millimeter markings
o A tongue blade
o A penlight or flashlight
o A Wood’s lamp
o A magnifying glass
 This equipment enables you to measure and closely inspect
skin lesions and other abnormalities

 Start by observing the skin’s overall appearance

 Such observation can help you identify areas that need further assessment
 Inspect and palpate the skin area by area, focusing on color, texture,
turgor, moisture, and temperature

Color:
 Look for localized areas for bruising, cyanosis, pallor, and erythema
 Check for uniformity of color and hypopigmented or hyperpigmented
areas
 Places exposed to the sun may show a darker pigmentation than other
areas
 Color changes may vary depending on skin pigmentation
 Be aware that some local skin color changes are normal variations that
appear in certain cultures

Detecting Color Variations in Dark-Skinned People

Cyanosis:
 Examine the conjunctivae, palms, soles, buccal mucosa, and tongue
 Look for full, dark color
Erythema:
 Palpate the area for warmth
Jaundice
 Examine the sclerae and hard palate in natural, not flourescent, light if possible
 Look for a yellow color
Pallor
 Examine the sclerae, conjunctivae, buccal mucosa, tongue, lips, nail beds, palms, and
soles
 Look for an ashen color
Petechiae
 Examine areas of lighter pigmentation such as the abdomen
Texture and Turgor:
 Inspect and palpate the skin’s texture, noting its thickness and mobility
 It should look smooth and be intact
 Rough, dry skin is common in patients with hypothyroidism, psoriasis, and
excessive keratinization
 Skin that isn’t intact may indicate local irritation or trauma

 Palpation also helps you evaluate the patient’s hydration status

 Dehydration and edema cause poor skin turgor
 Note, however, that because poor skin turgor may also be caused by aging
 It may not be a reliable indicator of an elderly patient’s hydration status
 Overhydration causes skin to appear edematous and spongy
 Localized edema can also result from trauma or systemic disease

Moisture:
 Observe the skin’s moisture content
 The skin should be relatively dry, with a minimal amount of perspiration
 Skin-fold areas should also be fairly dry
 Overly dry skin appears red and flaky

 Overly moist skin can be caused by anxiety, obesity, or an environment

that’s too warm
 Heavy sweating, or diaphoresis, usually accompanies fever; strenuous
activity; cardiac, pulmonary, and other diseases; and any activity or illness
that elevates metabolic rate
 Temperature:
 Palpate the skin bilaterally for temperature, which can range from cool to
warm
 Warm skin suggest normal circulation; cool skin, a possible underlying
disorder
 Distinguish between generalized and localized coolness and warmth
 Localized skin coolness can result from vasoconstriction associated with
cold environment or impaired arterial circulation to a limb
 General coolness can result from such conditions as shock or
hypothyroidism

 Localized warmth occurs in areas that are infected, inflamed, or burned

 Generalized warmth occurs with fever or systemic diseases such as
hyperthyroidism
 Be sure to check skin temperature bilaterally

Assessing Skin Temperature

When you’re trying to compare subtle temperature differences in one area of the body to
another, use the dorsal surface of the your hands and fingers
They’re the most sensitive to changes in temperature

Lesions:
 During your inspection, you may see normal variations in the skin’s texture
and pigmentation
 Red lesions caused by vascular changes include hemangiomas, scars,
telangiectases, petechiae, purpura, and ecchymoses and may indicate
disease

 Normal variations include birthmarks, freckles, and nevi, or moles

 Birthmarks are generally flat and range in color from tan to red or brown
 They can be found on all areas of the body
 Freckles are small, flat macules located primarily on the face, arms, and
back
 They’re usually red brown to brown
 Nevi are either flat or raised and may be pink, tan, or dark brown
 Like birthmarks, they can be found on all areas of the body

 When investigating a lesion, start by classifying it as primary or secondary

 A primary lesion is new
 Changes in a primary lesion constitute a secondary lesion
o Examples of secondary lesion include fissures, scales, crusts,
 Palpate the lesion to determine if it’s solid or fluid-filled
 Macules, papules, nodules, wheals, and hives are solid lesions
 You can also use a flashlight or penlight to determine whether a lesion is
solid or fluid-filled

 To identify lesions that fluoresce, use a Wood’s lamp, which gives out
specially filtered ultraviolet light
 Darken the room and shine the light on the lesion
 If the lesion looks bluish green, the patient has a fungal infection

 After you’ve identified the type of lesion, you’ll need to describe its
characteristics, pattern, location, and distribution
 A detailed description can help you determine whether the lesion is a
normal or pathologic skin change

 Examine the lesion to see if it looks the same on both sides

 Also, check the borders to see if they’re regular or irregular
 An asymmetrical lesion with an irregular border may include malignancy

 Lesions occur in various color and can change color overtime

 Therefore, watch for such changes in your patient
o For example, if a lesion such as a mole (nevus) has changed from tan
or brown to multiple shades of tan, dark brown, black, or a mixture
of red, white, and blue, the lesion might be malignant

 Pay close attention as well to the shape, configuration, and distribution of

the lesions
 Many skin diseases have typical configuration patterns
 Identifying those patterns can help you determine the cause of the
problem

 Measure the diameter of the lesion using a millimeter-centimeter ruler

 If you estimate the diameter, you may not be able to determine subtle
changes in size
 An increase in the size or elevation of a mole over many years is common
and probably normal
 Still, be sure to take note of moles that rapidly change size, especially
moles that are 6mm or larger

 If you note drainage, document the type, color, and amount

 Also note if the lesion has a foul odor, which can indicate a superimposed
infection

 Start inspecting and palpating the hair over the patient’s entire body, not
just on his head
 Note the distribution, quantity, texture, and color
 The quantity and distribution of head and body hair vary between patients
 However, hair should be evenly distributed over the entire body

 Check for patterns of hair loss and growth

 If you notice patchy hair loss, look for regrowth
 Also, examine the scalp for erythema, scaling, and encrustation
 Excessive hair loss with scalp crusting may indicate ringworm infestation
 The only way to detect scalp crusting is by using a Wood’s lamp
 Also, note areas of excessive hair growth, which may indicate a hormone
imbalance or be a sign of a systematic disorder such as Cushing’s
syndrome

 The texture of scalp hair also varies between patients

 As a rule, hair should be shiny and smooth, not dry or brittle
 Differences in grooming and use of hair products may affect the hair’s
texture and quality
 Dryness or brittleness can result from the use of harsh hair treatments or
hair care products or can be caused by a systemic illness
 Extreme oiliness is usually related to excessive sebum production or poor
grooming habits

 Assessing the nails is vital for two reasons:

o The appearance of the nails can be a critical indicator of systemic
illness
o Their overall condition tells you a lot about the patient’s grooming
habits and ability to care for himself
 Examine the nails for color, shape, thickness, consistency, and contour

 First, look at the color of the nails

 Light-skinned people generally have pinkish nails
 Dark-skinned people generally have brown nails
 Brown-pigmented bands in the nail beds are normal in dark-skinned people
and abnormal in light-skinned people
 Yellow nails may occur in smokers as a result of nicotine stains

 Nail beds can be used to assess a patient’s peripheral circulation

 Press on the nail bed and then release, noting how long the color takes to
return
 It should return immediately, or at least within 3 seconds

 Next, inspect the shape and contour of the nails

 The surface of the nail bed should be either slightly curved or flat
 The edges of the nail should be smooth, rounded, and clean

 The angle of the nail base is normally less than 180 degrees
 An increase in the nail angle suggests clubbing
 Curved nails are a normal variations
 They may appear to be clubbed until you notice that the nail angle is still
less than 180 degrees
  Finally, palpate the nail bed to check the thickness of the nail and the
strength of its attachment to the bed

 Various abnormalities may be found when assessing the skin, hair, and nails
 Because these abnormalities may be visible to others, the patient may
experience some degree of emotional stress
 Carefully document all abnormal findings, pertinent health history, and as
much information as possible from the physical examination

Skin, Hair, and Nail Abnormalities

After you assess the patient, a group of findings may lead you to suspect a particular
disorder. The chart below shows common groups of findings for the abnormal signs and
symptoms of the integumentary system, along with their probable cause

Signs or symptoms Probable cause Signs or Symptoms Probable cause

and findings and findings

Alopecia Arterial Pruritus

Patchy alopecia, insufficiency Intense, severe pruritis Atopic
typically on the Erythematous rash on dry skin at dermatitis
lower extremities flexion points
Thin, shiny, atrophic Possible edema, scaling, and
pustules
skin
Pediculosis
Thickened nails
Scalp excoriation from scratching capitis (head
Weak or absent Matted, foul-smelling, lusterless hair lice)
peripheral pulses Occipital and cervial
Cool extremities lymphadenopathy
Paresthesia Oval, gray-white nits on hair shafts Chronic renal
failure
Translucent charred Burns Gradual or sudden pruritus
or ulcerated skin Ammonia breath odor
Pain Oliguria or anuria
Fatigue
Hypothyroidism Irritability
Loss of the outer
third of the Muscle cramps
eyebrows
Thin, dull course, Anaphylaxis
Urticaria
brittle hair on the Rapid eruption of diffuse urticaria
face and angioedema, with wheals
Fatigue ranging from pinpoint to palm-size
Constipation or larger
Cold intolerance Pruritic, stinging lesions
Weight gain Profound anxiety
Puffy face, hands, Weakness
and feet Shortness of breath
Nasal congestion
Clubbing Dysphagia Hereditary
Warm moist skin angioedema
Anorexia
Emphysema
Malaise
Non-pitting, non-pruritic edema of Lyme disease
Dyspnea an extremity or the face
Tachypnea Possibly acute laryngeal edema
Diminished breath
sounds Erythema chronicum migrans that
Pursed-lip breathing results in urticaria
Barrel chest Constant malaise and fatigue
Peripheral cyanosis Fever
Chills
Wheezing Lymphadenopathy
Dyspnea Heart failure Neurologic and cardiac
abnormalities
Fatigue
Arthritis
Jugular vein
distention
Palpitations
Unexplained weight
gain
Dependent edema
Crackles on
auscultation

Hemoptysis
Dyspnea Lung and pleural
Wheezing cancer
Chest pain
Fatigue
Weight loss
Fever

SKIN COLOR VARIATIONS

COLOR DISTRIBUTION POSSIBLE CAUSE
Absent  Small circumscribed  Vitiligo
areas  Albinism
 Generalized
Blue  Around lips, buccal  Cyanosis (Note: in blacks, blue
mucosa, or gingivae are normal)
generalized
Deep red  Generalized  Polycythemia vera (increased red
blood cell count)
Pink  Local or generalized  Erythema (superficial capillary
dilation and congestion)
Tan to brown  Facial patches  Chloasma of pregnancy; butterfly rash
of lupus erythematosus
Tan to brown-  Generalized (not  Addison’s disease
bronze related to sun
exposure)
Yellow to  Sclera or generalized  Jaundice from liver dysfunction (Note:
yellowish in blacks, yellowish brown
brown pigmentation of sclera is normal)
Yellowish  Palms, soles, and  Carotenemia (carotene in the blood)
orange face; not sclera

 The signs and symptoms you detect during your assessment may be caused
by a wide variety of disorders

Cafè-au-lait spots
 Cafè-au-lait spots appears as flat, light brown, uniformly hyperpigmented
macules or patches on the skin surface
 They usually appear during the first 3 years of life but may develop at any
age
 Cafè-au-lait spots can be differentiated from freckles and other benign
birthmarks by their larger size and irregular shape
 They usually have no significance; however, six or more cafè-au-lait spots
may be associated with an underlying neurologic disorder such as
neurofibromatosis

Cherry Angiomas
 Cherry angiomas are tiny, bright red, round papules that may become
brown over time
 These clinically insignificant lesions occur in virtually everyone older than
age 30 and increase in number in age
Hemangiomas
 Hemangiomas, commonly called PORT-WINE STAINS or BIRTHMARKS, are
red skin lesions in the top layer of the skin (capillary hemangiomas)
 They are usually present at birth and commonly appear on the face and
upper body as flat purple marks
 Cavernous hemangiomas occur deeper in the skin and eventually distort
the skin

 Palpate the lesion to determine if it’s solid or fluid-filled

 Macules, papules, nodules, wheals, and hives are solid lesions
 You can also use a flashlight or penlight to determine whether a lesion is
solid or fluid-filled

 To identify lesions that fluoresce, use a Wood’s lamp, which gives out
specially filtered ultraviolet light
 Darken the room and shine the light on the lesion
 If the lesion looks bluish green, the patient has a fungal infection

 After you’ve identified the type of lesion, you’ll need to describe its
characteristics, pattern, location, and distribution
 A detailed description can help you determine whether the lesion is a
normal or pathologic skin change

 Examine the lesion to see if it looks the same on both sides

 Also, check the borders to see if they’re regular or irregular
 An asymmetrical lesion with an irregular border may include malignancy

 Lesions occur in various color and can change color overtime

 Therefore, watch for such changes in your patient
o For example, if a lesion such as a mole (nevus) has changed from tan
or brown to multiple shades of tan, dark brown, black, or a mixture
of red, white, and blue, the lesion might be malignant

 Pay close attention as well to the shape, configuration, and distribution of

the lesions
 Many skin diseases have typical configuration patterns
 Identifying those patterns can help you determine the cause of the
problem
 Measure the diameter of the lesion using a millimeter-centimeter ruler
 If you estimate the diameter, you may not be able to determine subtle
changes in size
 An increase in the size or elevation of a mole over many years is common
and probably normal
 Still, be sure to take note of moles that rapidly change size, especially
moles that are 6mm or larger

 If you note drainage, document the type, color, and amount

 Also note if the lesion has a foul odor, which can indicate a superimposed
infection

 Start inspecting and palpating the hair over the patient’s entire body, not
just on his head
 Note the distribution, quantity, texture, and color
 The quantity and distribution of head and body hair vary between patients
 However, hair should be evenly distributed over the entire body

 Check for patterns of hair loss and growth

 If you notice patchy hair loss, look for regrowth
 Also, examine the scalp for erythema, scaling, and encrustation
 Excessive hair loss with scalp crusting may indicate ringworm infestation
 The only way to detect scalp crusting is by using a Wood’s lamp
 Also, note areas of excessive hair growth, which may indicate a hormone
imbalance or be a sign of a systematic disorder such as Cushing’s
syndrome

 The texture of scalp hair also varies between patients

 As a rule, hair should be shiny and smooth, not dry or brittle
 Differences in grooming and use of hair products may affect the hair’s
texture and quality
 Dryness or brittleness can result from the use of harsh hair treatments or
hair care products or can be caused by a systemic illness
 Extreme oiliness is usually related to excessive sebum production or poor
grooming habits

 Assessing the nails is vital for two reasons:

o The appearance of the nails can be a critical indicator of systemic
illness
o Their overall condition tells you a lot about the patient’s grooming
habits and ability to care for himself
 Examine the nails for color, shape, thickness, consistency, and contour

 First, look at the color of the nails

 Light-skinned people generally have pinkish nails
 Dark-skinned people generally have brown nails
 Brown-pigmented bands in the nail beds are normal in dark-skinned people
and abnormal in light-skinned people
 Yellow nails may occur in smokers as a result of nicotine stains

 Nail beds can be used to assess a patient’s peripheral circulation

 Press on the nail bed and then release, noting how long the color takes to
return
 It should return immediately, or at least within 3 seconds

 Next, inspect the shape and contour of the nails

 The surface of the nail bed should be either slightly curved or flat
 The edges of the nail should be smooth, rounded, and clean

 The angle of the nail base is normally less than 180 degrees
 An increase in the nail angle suggests clubbing
 Curved nails are a normal variations
 They may appear to be clubbed until you notice that the nail angle is still
less than 180 degrees
 Finally, palpate the nail bed to check the thickness of the nail and the
strength of its attachment to the bed
  Various abnormalities may be found when assessing the skin, hair, and nails
 Because these abnormalities may be visible to others, the patient may
experience some degree of emotional stress
 Carefully document all abnormal findings, pertinent health history, and as
much information as possible from the physical examination

Skin, Hair, and Nail Abnormalities

After you assess the patient, a group of findings may lead you to suspect a particular
disorder. The chart below shows common groups of findings for the abnormal signs and
symptoms of the integumentary system, along with their probable cause

Signs or symptoms Probable cause Signs or Symptoms Probable cause

and findings and findings

Alopecia Arterial Pruritus

Patchy alopecia, insufficiency Intense, severe pruritis Atopic
typically on the Erythematous rash on dry skin at dermatitis
lower extremities flexion points
Thin, shiny, atrophic Possible edema, scaling, and
pustules
skin
Pediculosis
Thickened nails
Scalp excoriation from scratching capitis (head
Weak or absent Matted, foul-smelling, lusterless hair lice)
peripheral pulses Occipital and cervial
Cool extremities lymphadenopathy
Paresthesia Oval, gray-white nits on hair shafts Chronic renal
failure
Translucent charred Burns Gradual or sudden pruritus
or ulcerated skin Ammonia breath odor
Pain Oliguria or anuria
Fatigue
Hypothyroidism Irritability
Loss of the outer
third of the Muscle cramps
eyebrows
Thin, dull course, Anaphylaxis
Urticaria
brittle hair on the Rapid eruption of diffuse urticaria
face and angioedema, with wheals
Fatigue ranging from pinpoint to palm-size
Constipation or larger
Cold intolerance Pruritic, stinging lesions
Weight gain Profound anxiety
Puffy face, hands, Weakness
and feet Shortness of breath
Nasal congestion
Clubbing Dysphagia Hereditary
Anorexia Warm moist skin angioedema
Emphysema
Malaise
Non-pitting, non-pruritic edema of Lyme disease
Dyspnea
an extremity or the face
Tachypnea
Possibly acute laryngeal edema
Diminished breath
sounds Erythema chronicum migrans that
Pursed-lip breathing results in urticaria
Barrel chest Constant malaise and fatigue
Peripheral cyanosis Fever
Chills
Wheezing Lymphadenopathy
Dyspnea Heart failure Neurologic and cardiac
Fatigue abnormalities
Jugular vein Arthritis
distention
Palpitations
Unexplained weight
gain
Dependent edema
Crackles on
auscultation

Hemoptysis
Dyspnea Lung and pleural
Wheezing cancer
Chest pain
Fatigue
Weight loss
Fever

TSKIN COLOR VARIATIONS

COLOR DISTRIBUTION POSSIBLE CAUSE
Absent  Small circumscribed  Vitiligo
areas  Albinism
 Generalized
Blue  Around lips, buccal  Cyanosis (Note: in blacks, blue
mucosa, or gingivae are normal)
generalized
Deep red  Generalized  Polycythemia vera (increased red
blood cell count)
Pink  Local or generalized  Erythema (superficial capillary
dilation and congestion)
Tan to brown  Facial patches  Chloasma of pregnancy; butterfly rash
of lupus erythematosus
Tan to brown-  Generalized (not  Addison’s disease
bronze related to sun
exposure)
Yellow to  Sclera or generalized  Jaundice from liver dysfunction (Note:
yellowish in blacks, yellowish brown
brown pigmentation of sclera is normal)
Yellowish  Palms, soles, and  Carotenemia (carotene in the blood)
orange face; not sclera

 The signs and symptoms you detect during your assessment may be caused
by a wide variety of disorders

Cafè-au-lait spots
 Cafè-au-lait spots appears as flat, light brown, uniformly hyperpigmented
macules or patches on the skin surface
 They usually appear during the first 3 years of life but may develop at any
age
 Cafè-au-lait spots can be differentiated from freckles and other benign
birthmarks by their larger size and irregular shape
 They usually have no significance; however, six or more cafè-au-lait spots
may be associated with an underlying neurologic disorder such as
neurofibromatosis
Papular Rash
 A papular rash consists of small, raised, circumscribed – and perhaps
discolored (red to purple)- lesions known as PAPULES
 It may erupt anywhere on the body in various configurations and may be
acute or chronic
 Papular rashes characterize skin disorders; they may also result from
allergies or from infectious, neoplastic, and systemic disorders
Pressure Ulcers
 A pressure ulcer is a localized area of skin or tissue breakdown (or both)
that results from prolonged pressure, commonly over a bony prominence
  The pressure compromises the area’s vascular supply, leading to the
development of necrotic tissue
 Shear and friction also contribute to the breakdown
 Any pressure ulcer detected requires assessment and documentation;
many facilities also require a photograph of the affected area

Assessing Pressure Ulcers

Stage Description
Suspected deep  Purple or maroon area
tissue injury  Intact skin or blood filled blister
 May evolve and become covered with thin layer of eschar
Stage I  Reddened area of nonblanchable skin; difficult to detect in
dark-skinned patients
 Intact skin over bony prominence
 May be tender, with temperature difference from surrounding
tissue; may be hard or soft
Stage II  Red-pink shallow crater, blister, or abrasion without slough
 Partial-thickness tissue loss
Stage III  Deep crater that may extend to underlying fasciae; may have
undermining or tunneling
 Full-thickness tissue loss; no exposed bone or tendon
 Depth varies by anatomic location; may be shallow on areas
without adipose tissue, such as the nose or ear
Stage IV  Deep crater that extends to underlying fasciae; may have
undermining and tunneling
 Full-thickness tissue loss that exposes bone, tendon, or muscle
 Depth varies by anatomic location; may be shallow on areas
without subcutaneous fat, such as the nose and ear
Unstageable  Deep crater whose base is covered by slough, eschar, or both,
making it unstageable
 Full-thickness tissue loss

Pruritus
 Commonly provoking scratching to obtain relief, this unpleasant itching
sensation is the most common symptom of skin disorders
 Pruritus may also result from a local or systemic disorder, drug use,
emotional upset, or contact with skin irritants
 Pruritus may be exacerbated by increased skin temperature, poor skin
turgor, local vasodilation, dermatoses, and stress
 Purpuric Lesions
 Purpuric lesions are caused by red blood cells and blood pigments in the
skin, so they don’t blanch under pressure

 The three types of purpuric lesions are:

o Petechiae – red or brown pinpoint lesions generally caused by
capillary fragility; diseases associated with the formation of
microemboli or bleeding, such as subacute bacterial endocarditis and
thrombocytopenia, can cause petechiae
Purpuric Lesions
 Purpuric lesions are caused by red blood cells and blood pigments in the
skin, so they don’t blanch under pressure

 The three types of purpuric lesions are:

o Petechiae – red or brown pinpoint lesions generally caused by
capillary fragility; diseases associated with the formation of
microemboli or bleeding, such as subacute bacterial endocarditis and
thrombocytopenia, can cause petechiae
 Ecchymoses – bluish or purplish discolorations resulting from blood
accumulation in the skin after injury to the vessel walls
 Ecchymoses – bluish or purplish discolorations resulting from blood
accumulation in the skin after injury to the vessel walls
 Hematomas – masses of blood that accumulate in a tissue, organ, or body
space after a break in a blood vessel
 Purpuric lesions also produce deep red or reddish purple bruising that may
be caused by bleeding disorders such as disseminated intravascular
coagulation

Scars
 A scar consists of new collagen fibers that replace normal skin after the
dermis is injured
 Sweat glands and hair follicles don’t grow in scar tissue
 Initially, a scar may be red and raised, but it becomes flat and pale over
time
 How the wound heals determines a scar’s shape
  Overproduction of collagen tissue may result in a hypertrophic or keloid
scar

Types of Scars
Scar tissue forms when a wound heals. It has a different texture and quality than normal tissue.
Although typically a cosmetic problem, scars can still cause a patient distress

Several types of scars may form:

Acne scars – are pitting or sunken recesses in the skin that result from acne. They also called
ice-pick scars or depressed fibrotic scars
Contracture scar – is a tightening of the skin that may impede mobility. Such scars usually result
from a wound that affects muscle and nerves and commonly result from burns

Hypertrophic scar – is a red, raised bump on the skin that doesn’t exceed the wound
boundaries. Surgery or trauma cause these scars
Keloid scar – is an overgrowth of colloid tissue that results in a benign tumorous type of
growth. It can result from surgery, trauma, or acne
Stretch marks – also called striae distensae – are reddish or purple lines that fade to a lighter
color. They stem from dermal tearing during rapid growth, usually over areas where large
amounts of fat are stored, such as the abdomen, hips, or buttocks

Telangiectasis
 Telangiectasis are permanently dilated, small blood vessels that typically
form a weblike pattern
 For example, spider hemangiomas, a type of telangiectasis, are small, red
lesions arranged in a weblike configuration
 They usually appear on the face, neck, and chest and may be normal or
associated with pregnancy or cirrhosis
Telangiectasis
 Telangiectasis are permanently dilated, small blood vessels that typically
form a weblike pattern
 For example, spider hemangiomas, a type of telangiectasis, are small, red
lesions arranged in a weblike configuration
 They usually appear on the face, neck, and chest and may be normal or
associated with pregnancy or cirrhosis
Urticaria
 Urticaria is a vascular skin reaction characterized by the eruption of
transient pruritic wheals – smooth, slightly elevated patches with well-
defined erythematous margins and pale center of various shapes and sizes
  Urticaria lesions, also called HIVES, are produced by the local release of
histamine or other vasoactive substances as part of a hypersensitivity
reaction, commonly to certain drugs, foods, insect bites, inhalants, or
contact with certain substances
 Urticaria may also result from emotional stress or environmental factors
Vesicular rash
 A vesicular rash is a scattered or linear distribution of blisterlike lesions –
sharply curcumscribed and filled with clear, cloudy, or bloody fluid
 The lesions, which are usually less than 0.5cm in diameter, may occur singly
or in groups
 They sometimes occur with bullae – fluid-filled lesions larger than 0.5cm in
diameter

 A vesicular rash may be mild or severe and temporary or permanent

 It can result from infection, inflammation, or allergic reactions

 Typically stemming from other problems, hair abnormalities can cause

patients emotional distress
 Among the most common hair abnormalities are alopecia and hirsutism

Alopecia
 Alopecia occurs more commonly and extensively in men than in women
 Diffuse hair loss, although commonly a normal part of aging may occur as
result of pyrogenic infections, chemical trauma, ingestion of certain drugs,
and endocrinopathy and other disorders
 Tinea capitis, trauma, and third-degree burns can cause patchy hair loss
Hirsutism
 Excessive hairiness in women, or hirsutism, can develop on the body and
face, affecting the patient’s self-image
 Localized hirsutism may occur on pigmented nevi
 Generalized hirsutism can result from certain drug therapy or such
endocrine problems as Cushing’s syndrome and acromegaly

 Nail abnormalities are harmless, some point to serious underlying problems

 Common nail problems include Beau’s lines, clubbing, koilonychia,
Muehrcke’s lines, onycholysis, and Terry’s nails

Beau’s Lines
  Beau’s lines are transverse depressions in the nail that extend to the nail
bed
 These depressions occur at the same spot in most or all of the patient’s nail
beds
 They occur with acute illness, malnutrition, anemia, and trauma that
temporarily impairs nail function
 A dent appears first at the cuticle and then moves forward as the nail grows
Clubbing
 With clubbed fingers, the proximal edge of the nail elevates so the angle is
greater than 180 degrees
 The nail is also thickened and curved at the end, and the distal phalanx
looks rounder and wider than normal
 To check for clubbing, view the index finger in profile and note the angle of
the nail base
 Evaluating Clubbed Fingers

 Think hypoxia when you see a patient whose fingers are clubbed. To quickly examine a
patient’s fingers for early clubbing, gently palpate the bases of his nails. Normally, they’ll
feel firm, but in early clubbing, they’ll feel springy

 To evaluate late clubbing, have the patient place the first phalanges of the forefingers
together. Normal nail bases are concave and create a small, diamond-shaped space
when the first phalanges are opposed

 In late clubbing, the now convex nail bases can touch without leaving a space
(Schamroth’s sign). This conditon is associated with pulmonary and cardiovascular
disease
 When you spot clubbed fingers, think about the possible causes, such as emphysema,
chronic bronchitis, lung cancer, and chronic heart failure
Koilonychia
 Koilonychia refers to thin, spoon-shaped nails with lateral edges that tilt
upward, forming a concave profile
 The nails are white and opaque
 This condition is associated with hypochromic anemia, infections,
Raynaud’s disease, and malnutrition
Muehrcke’s lines
 Muehrcke’s lines are transverse bands of white that go across the nail in
pairs
 They disappear when the nail bed is depressed, which compresses the
vascular supply below the nail bed
  The lines don’t changes with nail growth because they occur within the
vascular bed
 Muehrcke’s lines are associated with hypoalbuminemia and disappear
when the albumin level returns to normal
Onycholysis
 Onycholysis is the loosening of the nail plate with separation from the nail
bed, which begins at the distal groove
 It’s associated with minor trauma to long fingernails and such disease
processes as psoriasis, contact dermatitis, hyperthyroidism, and
Pseudomonas infections
Terry’s nails
 In patient’s with Terry’s nails, the nail beds are white and look like ground
glass
 The lunula can’t be seen
 Terry’s nails may affect one or all nail beds
 This finding commonly occurs with severe liver disease