Health Assessment #3

Jaundice A yellowish skin color indicates rising amounts of bilirubin in the blood. Except for physiologic jaundice in the newborn (p. 222), jaundice does not occur normally. Jaundice is first noted in the junction of the hard and soft palate in the mouth and in the sclera. But do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons. The scleral yellow of jaundice extends up to the edge of the iris. As levels of serum bilirubin rise, jaundice is evident in the skin over the rest of the body. This is best assessed in direct natural daylight. Common calluses on palms and soles often look yellow—do not interpret these as jaundice.

-Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn. -Light or clay-colored stools and dark golden urine often accompany jaundice in both light- and dark-skinned people

Hematoma- A hematoma is a bruise you can feel. It elevates the skin and is seen as swelling. Multiple petechiae and purpura may occur on the face when prolonged, vigorous crying or coughing raises venous pressure.

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Inspecting the Hair

1) Color 2) Texture 3) Distribution 4) Lesions

Primary Skin lesions

1) Macule- Solely a color change, flat and circumscribed, of less than 1 cm. (Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever) 2) Patch- Macules that are larger than 1 cm. Examples: mongolian spot, vitiligo, café au lait spot, chloasma, measles rash. 3) Papule- Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca). 4) Plaque- Papules coalesce to form surface elevation wider than 1 cm. A plateau-like, disk-shaped lesion. Examples: psoriasis, lichen planus. 5) Nodule- Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi 6) Tumor - Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although "tumor" implies "cancer" to most people. Examples: lipoma, hemangioma 7) Wheal- Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism 8) Urticaria (hives)- Wheals coalesce to form extensive reaction, intensely pruritic 9) Vesicle- Elevated cavity containing free fluid, up to 1 cm; a "blister." Clear serum flows if wall is ruptured. Examples: herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis 10) Bulla- Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily. Examples: friction blister, pemphigus, burns, contact dermatitis 11) Cyst- Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Examples: sebaceous cyst, wen 12) Pustule- Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne.

Strawberry mark (immature hemangiomas)

A raised bright red area with well-defined borders about 2 to 3 cm in diameter. It does not blanch with pressure. It consists of immature capillaries, is present at birth or develops in the first few months, and usually disappears by age 5 to 7 years. Requires no treatment, although parental and peer pressure may prompt treatment.

Hemangiomas

Caused by a benign proliferation of blood vessels in the dermis.

Nail Color- The translucent nail plate is a window to the even, pink nail bed underneath. Dark-skinned people may have brown-black pigmented areas or linear bands or streaks along the nail edge (Fig. 12-9). All people normally may have white hairline linear markings from trauma or picking at the cuticle (Fig. 12-10). Note any abnormal marking in the nail beds

Cyanosis or marked pallor. Brown linear streaks (especially sudden appearance) are abnormal in light-skinned people and may indicate melanoma. Splinter hemorrhages, transverse ridges, or Beau's lines

Capillary Refill. Depress the nail edge to blanch and then release, noting the return of color. Normally, color return is instant, or at least within a few seconds in a cold environment. This indicates the status of the peripheral circulation. A sluggish color return takes longer than 1 or 2 seconds. Inspect the toenails. Separate the toes and note the smooth skin in between.

Cyanotic nail beds or sluggish color return: consider cardiovascular or respiratory dysfunction.

Sweat Glands: 2 types 1) Eccrine 2) Apocrine

Eccrine- coiled tubules that open directly onto the skin surface and produce a dilute saline solution= sweat -evaporation reduces body temp, mature in the 2 month old infant Apocrine-produce a thick, milky secretion and open into the hair follicle -located in the axillae, anogenital area, nipples, and navel and are vestigial in humans -active during puberty and secretions occur with emotional and sexual stimulation -decreases in the aging adult!

Edema is fluid accumulating in the intercellular spaces; it is not present normally. To check for edema, imprint your thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If your pressure leaves a dent in the skin, "pitting" edema is present. Its presence is graded on a four-point scale: 1+ mild pitting, slight identation, no perceptible swelling of the leg 2+ moderate pitting, indentation subsides rapidly 3+ deep pitting, identation lasts a long time, leg is very swollen Scale is subjective, outcomes can vary among examiners

Edema is most evident in dependent parts of the body (feet, ankles, and sacral areas), where the skin looks puffy and tight. Edema makes the hair follicles more prominent, so you note a pigskin or orange-peel look (called peau d'orange). Unilateral edema—consider a local or peripheral cause. Bilateral edema or edema that is generalized over the whole body (anasarca)—consider a central problem such as heart failure or kidney failure. Edema masks normal skin color and obscures pathologic conditions such as jaundice or cyanosis because the fluid lies between the surface and the pigmented and vascular layers. It makes dark skin look lighter.

Hypothermia. Generalized coolness may be induced, such as in hypothermia used for surgery or high fever. Localized coolness is expected with an immobilized extremity, as when a limb is in a cast or with an intravenous infusion.

General hypothermia accompanies central circulatory problem such as shock. Localized hypothermia occurs in peripheral arterial insufficiency and Raynaud's disease

Hair distribution

Hirsutism—excess body hair. In females, this forms a male pattern on the face and chest and indicates endocrine abnormalities -Absent or sparse genital hair suggests endocrine abnormalities

Nail surface is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded. Nail edges are smooth, rounded, and clean, suggesting adequate self-care.

Jagged nails, bitten to the quick, or traumatized nail folds suggest nervous picking habits. Chronically dirty nails suggest poor self-care or some occupations in which it is impossible to keep them clean.

Uremia—renal failure causes retained urochrome pigments in the blood

Light Skin- Orange-green or gray overlying pallor of anemia; may also have ecchymoses and purpura Dark Skin- Easily masked; rely on laboratory and clinical findings

Hair is vestigial, no longer needed for protection from cold or trauma

Mainly cosmetic and psychological -Hairs are threads of keratin. The hair shaft is the visible projecting part, and the root is below the surface embedded in the follicle. At the root the bulb matrix is the expanded area where new cells are produced at a high rate. Hair growth is cyclical, with active and resting phases. Each follicle functions independently so that while some hairs are resting, others are growing. Around the hair follicle are the muscular arrector pili, which contract and elevate the hair so that it resembles "goose flesh" when the skin is exposed to cold or in emotional states.

Mobility and Turgor- Pinch up a large fold of skin on the anterior chest under the clavicle (Fig. 12-5). Mobility is the skin's ease of rising, and turgor is its ability to return to place promptly when released. This reflects the elasticity of the skin.

Mobility is decreased with edema. Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or "tents" and stands by itself. Scleroderma, literally "hard skin," is a chronic connective tissue disorder associated with decreased mobility

Document presence of tattoos and that tattoos increase the risk for hepatitis C

Needle marks or tracks from intravenous injection of street drugs may be visible on the antecubital fossae, forearms, or on any available vein.

Texture of Hair

Note dull, coarse, or brittle scalp hair. Gray, scaly, well-defined areas with broken hairs accompany tinea capitis, a ringworm infection found mostly in school-age children

If any lesions present, note (CEPSLA): 1) Color 2) Elevation 3) Pattern or Shape 4) Size (cm) 5) Loation 6) Any Exudate

Palpate lesions. Wear a glove if you anticipate contact with blood, mucosa, any body fluid, or skin lesion. Roll a nodule between the thumb and index finger to assess depth. Gently scrape a scale to see if it comes off. Note the nature of its base or whether it bleeds when the scale comes off. Note the surrounding skin temperature. However, the erythema associated with rashes is not always accompanied by noticeable increases in skin temperature -Under the Wood's light, lesions with blue-green fluorescence indicate fungal infection (e.g., tinea capitis

Nail Consistency- smoothness, brittle, splitting, pits, normal grooves, thickness,

Pits, transverse grooves, or lines may indicate a nutrient deficiency or may accompany acute illness that disturbs nail growth Nails are thickened and ridged with arterial insufficiency

Pressure Ulcers

Pressure ulcers appear on the skin over a bony prominence when circulation is impaired. This occurs when a person is confined to bed or is immobilized. Immobilization impedes delivery of blood carrying oxygen and nutrients to the skin, and it impedes venous drainage carrying metabolic wastes away from the skin. This results in ischemia and cell death. Common sites for pressure ulcers are on the back (heel, ischium, sacrum, elbow, scapula, vertebra) or the side (ankle, knee, hip, rib, shoulder). Risk factors for pressure ulcers include impaired mobility, thin fragile skin of aging, decreased sensory perception (so unable to respond to pain accompanying prolonged pressure), impaired level of consciousness (also unable to respond), moisture from urine or stool incontinence, excessive perspiration or wound drainage, shearing injury (being pulled down or across in bed), poor nutrition, infection. Knowledge of risk factors and prevention of pressure ulcers is far more easily accomplished than is treatment of existing ulcers. However, once pressure ulcers occur, they are assessed by stage depending on the pressure ulcer depth

A newborn's skin is covered with fine downy lanugo especially in a preterm infant. Dark-skinned newborns have more lanugo than lighter-skinned newborns. Scalp hair may be lost in the few weeks after birth, especially at the temples and occiput. It grows back slowly.

Scaly, crusted scalp occurs with seborrheic dermatitis, "cradle cap"

Skin color in infants- The café au lait spot is a large round or oval patch of light brown pigmentation (hence, the name "coffee with milk"), which is usually present at birth (Fig. 12-13). Usually these patches are normal.

Six or more café au lait macules, each more than 1.5 cm in diameter, are diagnostic of neurofibromatosis, an inherited neurocutaneous disease.

Melanin protects the skin against harmful ultraviolet rays, a genetic advantage accounting for the lower incidence of skin cancer among darkly pigmented Blacks and American Indians

The incidence of melanoma is 20 times higher among whites than among Blacks and 4 times higher among whites than among Hispanics

Nails

hard plates of keratin on the dorsal edges of the fingers and toes -longitudinal ridges that become more prominent in aging -pink color from highly vascular epithelial cells underneath -lunula is white, opaque

The dermis is the inner supportive layer consisting mostly of connective tissue, or collagen. This is the tough, fibrous protein that enables the skin to resist tearing. The dermis also has resilient elastic tissue that allows the skin to stretch with body movements

mis is the inner supportive layer consisting mostly of connective tissue, or collagen. This is the tough, fibrous protein that enables the skin to resist tearing. The dermis also has resilient elastic tissue that allows the skin to stretch with body movements

Staging Pressure Ulcers (4 stages)

(p.237) Stage 1- Intact skin appears red but unbroken. Localized redness in lightly pigmented skin will blanch (turns light with fingertip pressure). Dark skin appears darker but does not blanch. Stage 2- Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. Stage 3- Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon. Stage 4- Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue).

Differences in hair among ethnicities

-Blacks- fragile, long to short, straight and spiraled, thick and kinky, dry scalp, require daily combining, gentle brushing, application of oil -Asian-straight/silky hair

Function of the skin - waterproof, almost indestructible, covering that has protective and adaptive properties:

-Protection. Skin minimizes injury from physical, chemical, thermal, and light-wave sources •Prevents penetration. Skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body •Perception. Skin is a vast sensory surface holding the neurosensory end-organs for touch, pain, temperature, and pressure •Temperature regulation. Skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation •Identification. People identify one another by unique combinations of facial characteristics, hair, skin color, and even fingerprints. Self-image is often enhanced or deterred by the way society's standards of beauty measure up to each person's perceived characteristics •Communication. Emotions are expressed in the sign language of the face and in the body posture. Vascular mechanisms such as blushing or blanching also signal emotional states •Wound repair. Skin allows cell replacement of surface wounds •Absorption and excretion. Skin allows limited excretion of some metabolic wastes, byproducts of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid, and urea •Production of vitamin D. The skin is the surface on which ultraviolet light converts cholesterol into vitamin D.

Pregnant Women- Skin

-The change in hormone levels results in increased pigment in the areolae and nipples, vulva, and sometimes in the midline of the abdomen (linea nigra) or in the face (chloasma). -Hyperestrogenemia probably also causes the common vascular spiders and palmar erythema -Connective tissue develops increased fragility, resulting in striae gravidarum (stretch marks), which may develop in the skin of the abdomen, breasts, or thighs -Metabolism is increased in pregnancy; as a way to dissipate heat, the peripheral vasculature dilates and the sweat and sebaceous glands increase secretion -Fat deposits are laid down, particularly in the buttocks and hips, as maternal reserves for the nursing baby.

Aging Adult- Skin

-The skin is a mirror that reflects aging changes that proceed in all our organ systems; it just happens to be the one organ we can view directly -slow atrophy of skin structures. The aging skin loses its elasticity; it folds and sags. By the 70s to 80s, it looks parchment thin, lax, dry, and wrinkled. -Epidermis flattens and thins (chemicals easier access) -Wrinkling occurs in underlying dermis as it thins and flattens -Loss of elastin, collagen, and subcutaneous fat as well as reduction in muscle tone -Loss of collagen increases the risk of shearing and tearing injuries -Sweat glands and sebaceous glands decrease in number and function, leaving dry skin. Decreased response of the sweat glands to thermoregulatory demand also puts the aging person at greater risk for heat stroke. The vascularity of the skin diminishes while the vascular fragility increases; a minor trauma may produce dark red discolored areas, or senile purpura

Cyanosis This is a bluish mottled color that signifies decreased perfusion; the tissues do not have enough oxygenated blood. Be aware that cyanosis can be a nonspecific sign. A person who is anemic could have hypoxemia without ever looking blue, because not enough hemoglobin is present (either oxygenated or reduced) to color the skin. On the other hand, a person with polycythemia (an increase in the number of red blood cells) looks ruddy blue at all times and may not necessarily be hypoxemic. This person just cannot fully oxygenate the massive numbers of red blood cells. Last, do not confuse cyanosis with the common and normal bluish tone on the lips of dark-skinned persons of Mediterranean origin.

-difficult to observe in darkly pigmented persons Given that most conditions causing cyanosis also cause decreased oxygenation of the brain, other clinical signs—such as changes in level of consciousness and signs of respiratory distress—will be evident. -Cyanosis indicates hypoxemia and occurs with shock, heart failure, chronic bronchitis, and congenital heart disease

Aging Hair Matrix

-number of functioning melanocytes decreases so the hair looks grey or white and feels thin and fine -a person's genetic script determines the onset of graying and the number of gray hairs -Hair distribution changes: Males have a symmetric W shaped balding in the frontal areas With decreasing testosterone with aging, axillary and pubic hair decreases As females estrogen decreases, testosterone is unopposed and the female may develop bristly facial hairs Nails grow more slowly- lusterless, local trauma in nail matrix

Adolescents- The increase in sebaceous gland activity creates increased oiliness and acne Acne is the most common skin problem of adolescence Almost all teens have some acne, even in the milder form of open comedones (blackheads) and closed comedones (whiteheads). Severe acne includes papules, pustules, and nodules Acne lesions usually appear on the face and sometimes on the chest, back, and shoulders. Acne may appear in children as early as 7 to 8 years of age; then the lesions increase in number and severity and peak at 14 to 16 years in girls and at 16 to 19 years in boys.

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Aging Adult- Sebaceous hyperplasia consists of raised yellow papules with a central depression. They are more common in men, occurring over the forehead, nose, or cheeks. They have a pebbly look Thickness. With aging, the skin looks as thin as parchment and the subcutaneous fat diminishes. Thinner skin is evident over the dorsa of the hands, forearms, lower legs, dorsa of feet, and over bony prominences. The skin may feel thicker over the abdomen and chest. Mobility and Turgor. The turgor is decreased (less elasticity), and the skin recedes slowly or "tents" and stands by itself

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Aging Adult- Hair- With aging, the hair growth decreases and the amount decreases in the axillae and pubic areas. After menopause, white women may develop bristly hairs on the chin or upper lip resulting from unopposed androgens In men, coarse terminal hairs develop in the ears, nose, and eyebrows, although the beard is unchanged. Male-pattern balding, or alopecia, is a genetic trait. It is usually a gradual receding of the anterior hairline in a symmetric W shape. In men and women, scalp hair gradually turns gray because of the decrease in melanocyte function

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An accumulation of factors place the aging person at risk for skin disease and breakdown: -the thinning of the skin -the decrease in vascularity and nutrients - the loss of protective cushioning of the subcutaneous layer -a lifetime of environmental trauma to skin, the social changes of aging (e.g., less nutrition, limited financial resources), the increasingly sedentary lifestyle, and the chance of immobility - When skin breakdown does occur, subsequent cell replacement is slower and wound healing is delayed.

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Change in Skin in Infants- Texture A common variation occurring in the infant is milia Milia are tiny while papules on the cheeks and forehead and across the nose and chin caused by sebum that occludes the opening of the follicles. Tell parents not to squeeze the lesions; milia resolve spontaneously within a few weeks.

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Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years (Fig. 12-6). They normally increase in size and number with aging and are not significant.

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Erythema Intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries. This sign is expected with fever, with local inflammation, or with emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest) -The erythema with fever or localized inflammation has an increased skin temperature from the increased rate of blood flow. Because you cannot see inflammation in dark-skinned persons, it is necessary to palpate the skin for increased warmth, taut or tightly pulled surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels. -Erythema occurs with polycythemia, venous stasis, carbon monoxide poisoning, and the extravascular presence of red blood cells (petechiae, ecchymosis, hematoma)

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Erythema- Hyperemia—increased blood flow through engorged arterioles, such as in inflammation, fever, alcohol intake, blushing Light Skin- Red, bright Dark Skin- purplish tinge, difficult to see, palpate for warmth with inflammation, taut skin, hardening of deep tissues

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From the basal layer the new cells migrate up and flatten into the outer horny cell layer. This consists of dead keratinized cells that are interwoven and closely packed. The cells are constantly being shed, or desquamated, and are replaced with new cells from below. The epidermis is completely replaced every 4 weeks -skin color is also modified from thickness and by presence of edema

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Infants and Children- The hair follicles develop in the fetus at 3 months' gestation; by midgestation, most of the skin is covered with lanugo, the fine downy hair of the newborn infant. In the first few months after birth, this is replaced by fine vellus hair. Terminal hair on the scalp, if present at birth, tends to be soft and to suffer a patchy loss, especially at the temples and occiput. Also present at birth is vernix caseosa, the thick, cheesy substance made up of sebum and shed epithelial cells.

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Lyme disease (LD) is not fatal but may have serious arthritic, cardiac, or neurologic sequelae. It is caused by a spirochete bacterium carried by the black or dark brown deer tick. Deer ticks are common in the Northeast, upper Midwest, and California (with cases occurring in people who spend time outdoors) in May through September. The first stage (early localized LD) has the distinctive bull's eye, red macular or papular rash (shown above) in 50% of cases. The rash radiates from the site of the tick bite (5 cm or larger), with some central clearing, and is usually located in axillae, midriff, inguina, or behind knees, with regional lymphadenopathy. Rash fades in 4 weeks; untreated individual then may have disseminated disease with fatigue, anorexia, fever, chills, joint or muscle aches. Antibiotic treatment shortens symptoms and decreases risk for sequelae.

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Note the location of these cranial bones: frontal, parietal, occipital, and temporal. Use these names to describe any of your clinical findings in the corresponding areas.

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Pattern injury is a bruise or wound whose shape suggests the instrument or weapon that caused it (e.g., belt buckle, broomstick, burning cigarette, pinch marks, bite marks, or scalding-hot liquid). Inflicted scalding-water immersion burns usually have a clear border, like a glove or sock, indicating that body part was held under water intentionally. Deformity results from an untreated fracture because the bone heals out of alignment. These physical signs suggest child abuse, together with a history that does not match the severity or type of injury, and indicate impaired or dysfunctional parent-child relationship.

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People have two types of hair. Fine, faint vellus hair covers most of the body (except the palms and soles, the dorsa of the distal parts of the fingers, the umbilicus, the glans penis, inside the labia). The other type is terminal hair, the darker, thicker hair that grows on the scalp and eyebrows and, after puberty, on the axillae, the pubic area, and the face and chest in the male.

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Port wine stain (Nevus Flammeus)- A large, flat, macular patch covering the scalp or face, frequently along the distribution of cranial nerve V. The color is dark red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat or cold. The marking consists of mature capillaries. It is present at birth and usually does not fade. The use of yellow light lasers now makes photoablation of the lesion possible, with minimal adverse effects.

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Pregnant woman- Striae are jagged linear "stretch marks" of silver to pink color that appear during the second trimester on the abdomen, breasts, and sometimes thighs. They occur in one half of all pregnancies. They fade after delivery but do not disappear Another skin change on the abdomen is the linea nigra, a brownish black line down the midline Chloasma is an irregular brown patch of hyperpigmentation on the face. It may occur with pregnancy or in women taking oral contraceptive pills. Chloasma disappears after delivery or stopping the pills Vascular spiders occur in two thirds of pregnancies in white women and less often in Blacks. These lesions have tiny red centers with radiating branches and occur on the face, neck, upper chest, and arms.

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Primary Lesions- The immediate result of a specific causative factor; primary lesions develop on previously unaltered skin.

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Skin color in infants- The mongolian spot is a common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns It is a blue-black to purple macular area at the sacrum or buttocks but sometimes on the abdomen, thighs, shoulders, or arms. It is due to deep dermal melanocytes. It gradually fades during the first year. By adulthood, these spots are lighter but are frequently still visible. Mongolian spots are present in 90% of Blacks, 80% of Asians and American Indians, and 9% of whites. If you are unfamiliar with mongolian spots, be careful not to confuse them with bruises. Recognition of this normal variation is particularly important when dealing with children who might be erroneously identified as victims of child abuse.

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Skin color- Carotenemia also produces a yellow-orange color in light-skinned persons but no yellowing in the sclera or mucous membranes It comes from ingesting large amounts of foods containing carotene, a vitamin A precursor. Carotene-rich foods are popular as prepared infant foods, and the absorption of carotene is enhanced by mashing, pureeing, and cooking. The color is best seen on the palms and soles, the forehead, tip of the nose and nasolabial folds, the chin, behind the ears, and over the knuckles; it fades to normal color within 2 to 6 weeks of withdrawing carotene-rich foods from the diet.

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Skin- As the child grows: the epidermis thickens, toughens, and darkens and the skin becomes better lubricated Hair growth accelerates. At puberty: Secretion from apocrine sweat glands increases in response to heat and emotional stimuli, producing body odor Sebaceous glands become more active—the skin looks oily, and acne develops Subcutaneous fat deposits increase, especially in females.

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Some vascular markings are common birthmarks in the newborn. A storkbite (salmon patch) is a flat, irregularly shaped red or pink patch found on the forehead, eyelid, or upper lip but most commonly at the back of the neck (nuchal area) (Fig. 12-17). It is present at birth and usually fades during the first year.

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Sun exposure and cigarette smoking further accentuate aging changes in the skin Course wrinkling, decreased elasticity, atrophy, speckled and uneven coloring, more pigment changes, and a yellowed, leathery texture occur. Chronic sun damage is even more prominent in pale or light-skinned persons.

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The Aging Adult- Hyperpigmentations: 1) Senile Lentigines. Commonly called liver spots, these are small, flat, brown macules These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure. They appear on the forearms and dorsa of the hands. They are not malignant and require no treatment. 2) Keratoses. These lesions are raised, thickened areas of pigmentation that look crusted, scaly, and warty. One type, seborrheic keratosis, looks dark, greasy, and "stuck on" They develop mostly on the trunk but also on the face and hands and on unexposed as well as on sun-exposed areas. They do not become cancerous. 3) Another type, actinic (senile or solar) keratosis, is less common These lesions are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma.

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The Regional Examination -At times, your assessment will be focused on the skin alone Help the person remove clothing, and assess the skin as one entity Stand back at first to get an overall impression; this helps reveal distribution patterns Then inspect lesions carefully. With a skin rash, check all areas of the body because some locations the person cannot see You cannot rely on the history alone that the rash is limited to one location Inspect mucous membranes, too, because some disorders have characteristic lesions here.

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The skin has two layers—the outer, highly differentiated epidermis and the inner, supportive dermis. Beneath these layers is a third layer, the subcutaneous layer of adipose tissue.

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There are several skin conditions found among Blacks: 1) Keloids—scars that form at the site of a wound and grow beyond the normal boundaries of the wound (see p. 235) 2) Areas of either postinflammatory hypopigmentation or hyperpigmentation that appear as dark or light spots 3) Pseudofolliculitis—"razor bumps" or "ingrown hairs" caused by shaving too closely with an electric razor or straight razor 4) Melasma—the "mask of pregnancy," a patchy tan to dark brown discoloration of the face

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Skin color change in infants- Two temporary cyanotic conditions may occur:

1) A newborn may have acrocyanosis, a bluish color around the lips, hands and fingernails, and feet and toenails. This may last for a few hours and disappear with warming. -persistant indicates distress such as cyanotic congenital heart disease 2) Cutis marmorata is a transient mottling in the trunk and extremities in response to cooler room temperatures. It forms a reticulated red or blue pattern over the skin. -Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity -Green-brown discoloration of the skin, nails, and cord occurs with passing of meconium in utero, indicating fetal distress.

Shapes of lesions

1) Annular- circular, begins in center and spreads to periphery (ring worm, tinea versicolor, pityriasis rosea) 2) Confluent- lesions run together (urticaria) 3) Discrete- distinct, individual lesions that remain separate (acne, skin tags) 4) Grouped- clusters of lesions (dermatitis) 5) Gyrate- twisted, coiled, spiral, snakelike 6) Target- iris, resembles iris of the eye, concentric rings (eythema multiforme) 7) Linear- scratch, streak, line, stripe 8) Polycyclic- annular lesions grow togther (psoriasis, lichen planus) 9) Zosteriform- linear arrangement along a unilateral nerve route (herpes zoster)

Inspect and palpate the skin (p.213)

1) Color- general pigmentation, freckles, moles, tattoos, birthmarks, lesions Abnormal findings-An acquired condition is vitiligo, the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices. Vitiligo can occur in all races, although dark-skinned people are more severely affected and potentially suffer a greater threat to their body image Danger signs: ABCDE Assymetry- not regular oval or round, two halfs dont look the same Border Irregularity-notching, scalloping, ragged edges Color Variation- areas of brown, black, blue Diameter- greater than 6 mm Elevation or enlargement

Secondary Skin lesions

1) Crust- The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on the fluid's ingredients (blood, serum, pus). Examples: impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion. 2) Scale- Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin 3) Fissure- Linear crack with abrupt edges, extends into dermis, dry or moist. Examples: cheilosis—at corners of mouth due to excess moisture; athlete's foot. 4) Erosion-Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis. 5) Ulcer- Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure sore, chancre. 6) Excoriation- Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella. 7) Scar- After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Examples: healed area of surgery or injury, acne. 8) Atrophic Scar- The resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Example: striae. 9) Lichenification- Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen). 10) Keloid- A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. May increase long after healing occurs. Looks smooth, rubbery, and "clawlike" and has a higher incidence among Blacks.

Hair, Skin, Nail Examination

1) Inspect the skin -Color -General Pigment- Areas of Hypopigmentation/Hyperpigmentation -Abnormal Color Changes 2) Palpate the Skin -Temp -Moisture -Texture -Thickness -Edema -Mobility and Turgor -Hygiene -Vascularity or Bruising 3) Note any Lesions -Color -Shape and Configuration -Size -Location and distribution on body 4) Inspect and Palpate the Hair -Texture -Distribution -Any scalp lesions 5) Inspect and palpate the nails -Shape and contour -Consistency -Color 6) Teach skin self examination

Inspecting the Nails

1) Shape and contour 2) Profile Sign 3) Consistency 4) Color 5) Capillary Refill

Skin color change in infants- Three erythematous states are common variations in the neonate:

1)The newborn's skin has a beefy red flush for the first 24 hours because of vasomotor instability; then the color fades to its normal color. 2)Another finding, the harlequin color change, occurs when the baby is in a side-lying position. The lower half of the body turns red and the upper half blanches with a distinct demarcation line down the midline. The cause is unknown, and its occurrence is transient. 3)Finally, erythema toxicum is a common rash that appears in the first 3 to 4 days of life. Sometimes called the "flea bite" rash or newborn rash, it consists of tiny punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks (Fig. 12-14). The cause is unknown; no treatment is needed.

Contusion (bruise)

A mechanical injury (e.g., a blow) results in hemorrhage into tissues. Skin is intact. Color in a light-skinned person is usually (1) red-blue or purple immediately after or within 24 hours of trauma, then generally progresses to (2) blue to purple, (3) blue-green, (4) yellow, and (5) brown to disappearing. A recent bruise in a dark-skinned person is deep, dark purple. Note that it is not possible to date the age of a bruise from its color. Pressure on a bruise will not cause it to blanch. A bruise usually occurs from trauma; also from bleeding disorders and liver dysfunction. Note that a bruise is different from petechiae, ecchymosis, and purpura, because the latter three are not caused by blunt force trauma

Cavernous Hemangioma ( Mature)

A reddish blue, irregularly shaped, solid and spongy mass of blood vessels. It may be present at birth, may enlarge during the first 10 to 15 months, and will not involute spontaneously.

Texture

Abnormal- Hyperthyroidism—skin feels smoother and softer, like velvet. Hypothyroidism—skin feels rough, dry, and flaky

Because the aging changes in the skin and hair can be viewed directly, they carry a profound psychological impact. For many people, self-esteem is linked to a youthful appearance.

Although sagging and wrinkling skin and graying and thinning hair are normal processes of aging, they prompt a loss of self-esteem for many adults.

Local arterial insufficiency

Appearance Light Skin -Mark localized pallor (lower extremities esp when elevated) Dark Skin- Ashen grey, dull, cool to touch

Skin Color in Infants—General Pigmentation. Black newborns initially have lighter-toned skin than their parents because of a pigment function that is not yet in full production. Their full melanotic color is evident in the nail beds and scrotal folds.

Bruising is a common soft tissue injury that follows a rapid traumatic or breach birth.

The Profile Sign. View the index finger at its profile and note the angle of the nail base; it should be about 160 degrees (Fig. 12-8). The nail base is firm to palpation. Curved nails are a variation of normal with a convex profile. They may look like clubbed nails, but notice that the angle between nail base and nail is normal (i.e., 160 degrees or less)

Clubbing of nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. In early clubbing, the angle straightens out to 180 degrees and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows

Changing Skin color with emotions/Environment, causes, misleading outcome

Emotions 1) Fear, anger- peripheral vasoconstriction-false pallor 2) Embarrassment- flushing in the face and neck-false erythema Environment 1) Hot Room- vasodilation-false erythema 2) Chilly room- vasoconstriction-false pallor, coolness Physical 1) prolonger elevation- decreased arterial perfusion-pallor, coolness 2) dependent position- venous pooling- redness, warmth, distended veins 3) Immobilization/prolonged inactivity- slowed circulation- pallor coolness, nail beds pale, prolonged capillary filling time

The epidermis is thin but tough. Its cells are bound tightly together into sheets that form a rugged protective barrier. It is stratified into several zones. The inner basal cell layer forms new skin cells. Their major ingredient is the tough, fibrous protein keratin. The melanocytes interspersed along this layer produce the pigment melanin, which gives brown tones to the skin and hair. All people have the same number of melanocytes; however, the amount of melanin they produce varies with genetic, hormonal, and environmental influences

From the basal layer the new cells migrate up and flatten into the outer horny cell layer. This consists of dead keratinized cells that are interwoven and closely packed. The cells are constantly being shed, or desquamated, and are replaced with new cells from below. The epidermis is completely replaced every 4 weeks. -epidermis is avascular, nourished by BV in the dermis -palms and soles are exposed to friction so they may be a little thicker. Other than that, the skin is uniform

Aging Adult- Nails- With aging, the nail growth rate decreases and local injuries in the nail matrix may produce longitudinal ridges. The surface may be brittle or peeling and sometimes yellowed. Toenails also are thickened and may grow misshapen, almost grotesque. The thickening may be a process of aging, or it may be due to chronic peripheral vascular disease.

Fungal infections are common in aging, with thickened, crumbling toenails and erythematous scaling on contiguous skin surfaces.

Hyperthermia. Generalized hyperthermia occurs with an increased metabolic rate, such as in fever or after heavy exercise. A localized area feels hyperthermic with trauma, infection, or sunburn.

Hyperthyroidism has an increased metabolic rate, causing warm, moist skin.

The apocrine and eccrine sweat glands are important for fluid balance and for thermoregulation When apocrine gland secretions are contaminated by normal skin flora, odor results Most Asians and American Indians have a mild body odor or none at all, whereas whites and Blacks tend to have strong body odor The amount of chloride excreted by sweat glands varies widely, and Blacks have lower salt concentrations in their sweat than whites do.

In Arctic regions, Inuits have made an interesting environmental adaptation; they sweat less than whites on their trunks and extremities but more on their faces This adaptation allows for temperature regulation without causing perspiration and dampness of their clothes, which would decrease their ability to insulate against severe cold weather and would pose a serious threat to their survival

Indoor Tanning

Increases risk for melanoma and non-melanoma skin cancer (squamous cell and basal cell carcinomas)

Jaundice. A yellowish skin color indicates rising amounts of bilirubin in the blood. Except for physiologic jaundice in the newborn jaundice does not occur normally. Jaundice is first noted in the junction of the hard and soft palate in the mouth and in the sclera. But do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons. The scleral yellow of jaundice extends up to the edge of the iris. -As levels of serum bilirubin rise, jaundice is evident in the skin over the rest of the body. This is best assessed in direct natural daylight. Common calluses on palms and soles often look yellow—do not interpret these as jaundice.

Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn. -Light or clay-colored stools and dark golden urine often accompany jaundice in both light- and dark-skinned people.

Skin color change in Infants- Physiologic jaundice is a common variation in about half of all newborns A yellowing of the skin, sclera, and mucous membranes develops after the 3rd or 4th day of life because of the increased numbers of red blood cells that hemolyze after birth The hemoglobin in the red blood cells is metabolized by the liver and spleen; its pigment is converted into bilirubin.

Jaundice on the first day of life may indicate hemolytic disease. Jaundice after 2 weeks of age may indicate biliary tract obstruction

Addison's disease—cortisol deficiency stimulates increased melanin production

Light Skin- Bronzed appearance, an "eternal tan," most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbow, axillae) Dark Skin- Easily masked; rely on laboratory and clinical findings

Café au lait spots—caused by increased melanin pigment in basal cell layer

Light Skin- Tan to light brown, irregularly shaped, oval patch with well-defined borders

Jaundice- Increased serum bilirubin, more than 2 to 3 mg/100 mL from liver inflammation or hemolytic disease, such as after severe burns, some infections

Light Skin- Yellow in sclera, hard palate, mucous membranes, then over skin Dark Skin- Check sclera for yellow near limbus; do not mistake normal yellowish fatty deposits in the periphery under the eyelids for jaundice—jaundice best noted in junction of hard and soft palate and also palms

Carotenemia—increased serum carotene from ingestion of large amounts of carotene-rich foods

Light Skin- Yellow-orange in forehead, palms and soles, nasolabial folds, but no yellowing in sclera or mucous membranes Dark skin- Yellow-orange tinge in palms and soles

Carbon Monoxide Poisoning

Light skin- Bright cherry red in face and upper torso Dark Skin- Cherry red color in nail beds, lips, and oral mucosa

Polycythemia—increased red blood cells, capillary stasis

Light skin- Ruddy blue in face, oral mucosa, conjunctiva, hands and feet Dark Skin- Well concealed by pigment—check for redness in lips

Cyanosis- Increased amount of unoxygenated hemoglobin Central—chronic heart and lung disease cause arterial desaturation

Light skin- dusky blue Dark Skin- Dark but dull lifeless, only severe is apparent (check oral, conjuctivae, oral mucosa, nail beds)

Albinism- absence of pigment melanin throughout the integument

Light skin- whitish pink Dark Skin- tan, cream, white

Widespread Color Change Note any color change over the entire body skin, such as pallor (white), erythema (red), cyanosis (blue), and jaundice (yellow). Note whether the color change is transient and expected or whether it is due to pathology -in dark skinned people, amount of normal prigment may mask color changes, look under the tongue, buccal mucosa, palpebrale conjuctiva, schlera (least pigmentation)

Pallor When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white. Pallor is common in acute high-stress states, such as anxiety or fear, because of the powerful peripheral vasoconstriction from sympathetic nervous system stimulation. The skin also looks pale with vasoconstriction from exposure to cold and cigarette smoking, and in the presence of edema. -Ashen gray color in dark skin or marked pallor in light skin occurs with anemia, shock, arterial insufficiency Can indicate anemia- decreased hematocrit Can indicate shock- decreased perfusion, vasoconstriction In light skin- generalized pallor In dark skin- appears yellow brown, dull In black skin- ashen gray, dull

Herpes Zoster (shingles)

Small, grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Caused by the varicella zoster virus (VZV), a reactivation of the dormant virus of chickenpox. Acute appearance, unilateral, does not cross midline. Commonly on trunk, can be anywhere. If on ophthalmic branch of cranial nerve V, it poses risk to eye. Most common in adults older than 50 years. Pain is often severe and long lasting in aging adults, called postherpetic neuralgia

Squamous Cell Carcinoma

Squamous cell cancers arise from actinic keratoses or de novo. Erythematous scaly patch with sharp margins, 1 cm or more. Develops central ulcer and surrounding erythema. Usually on hands or head, areas exposed to UV radiation; above, on habitually sun-exposed bald scalp. Less common than basal cell carcinoma but grows rapidly.

The subcutaneous layer is adipose tissue which is made up of lobules of fat cells

Stores fat for energy, provides insulation for temp control and aids in protection by its soft cushioning effect. -loose subcutaneous layer gives skin its increased mobility over structures underneath

Hair condition is significant in diagnosing and treating certain disease states For example, hair texture becomes dry, brittle, and lusterless with inadequate nutrition. The hair of Black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but also in color. The child's hair often becomes less kinky and assumes a copper-red color.

Subjective Data- (p.208) 1 Past history of skin disease (allergies, hives, psoriasis, eczema) "any past skin disease or problem?" 2 Change in pigmentation 3 Change in mole (size or color) 4 Excessive dryness or moisture 5 Pruritus 6 Excessive bruising 7 Rash or lesion 8 Medications 9 Hair loss 10 Change in nails 11 Environmental or occupational hazards 12 Self-care behaviors

Promoting health and self care

Teach all adults to examine their skin once a month, using the ABCDE rule to raise warning signals of any suspicious lesions. Use a well-lighted room that has a full-length mirror. It helps to have a small handheld mirror. Ask a family member to search skin areas difficult to see. Report any suspicious lesions promptly to a physician or nurse.

The newborn's skin is similar in structure to the adult's, but many of its functions are not fully developed. The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss. Sebum, which holds water in the skin, is present for the first few weeks of life, producing milia (see p. 222) and cradle cap in some babies.

Then sebaceous glands decrease in size and production and do not resume functioning until puberty Temperature regulation is ineffective Eccrine sweat glands do not secrete in response to heat until the first few months of life and then only minimally throughout childhood The skin cannot protect much against cold because it cannot contract and shiver and because the subcutaneous layer is inefficient Also, the pigment system is inefficient at birth.

Sebaceous Glands

These glands produce a protective lipid substance, sebum, which is secreted through the hair follicles. Sebum oils and lubricates the skin and hair and forms an emulsion with water that retards water loss from the skin. (Dry skin results from loss of water, not directly from loss of oil.) -Everywhere except the palms and soles -Most abundant in scalp, forehead, face and chin

Skin, Hair, Nails- Objective Data

Try to control external variables that may influence skin color or confuse findings - direct lighting (natural daylight is ideal) -the danger is one of omission- grow so accustomed to seeing the skin, you may ignore it as you assess the organ systems underneath. Information regarding: Nutrition, circulation, systemic diseases -know baseline knowledge to asses color or pigment changes-ask about usual skin color and any self monitoring practies -Skin assessment is integrated throughout the complete examination, not a separate step -Begin with Nails, then look over skin then go over underlying structures -Dont forget the skin folds of breasts and abdomen and taking the socks off to see the feet

Basal Cell Carcinoma

Usually starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel). Then develops rounded, pearly borders with central red ulcer, or looks like large open pore with central yellowing. Most common form of skin cancer; slow but inexorable growth. Basal cell cancers occur on sun-exposed areas of face, ears, scalp, shoulders

A callus is a circumscribed overgrowth of epidermis and is an adaptation to excessive pressure from the friction of work and weight bearing.

Very thin, shiny skin (atrophic) occurs with arterial insufficiency