chapter 14 health assessment

abnormal

A strong odor of perspiration or foul odor may indicate disorder of sweat glands. Poor hygiene practices may indicate a need for client education or assistance with activities of daily living.

There are five major types of tattoos:

1 Traumatic, caused by debris embedded in skin, as after a motorcycle accident 2 Amateur, placed by nonprofessionals using India ink with a pin 3 Professional, applied by a professional or skilled tattoo artist 4 Medical, used to delineate a landmark for radiation 5 Cosmetic, used for permanent eyeliner, lipstick, hair, blush, or eyebrows

What kinds of foods do you consume in a typical day? How much fluid do you drink each day?

A balanced diet is necessary for healthy skin, hair, and nails. Adequate fluid intake is required to maintain skin elasticity.

Has anyone in your family had skin cancer?

A genetic component is associated with skin cancer, especially malignant melanoma

Do you have a history of smoking and/or drinking alcohol?

A significant association between cigarette smoking, alcohol consumption, and psoriasis has been found

abnormal

Cold skin may accompany shock or hypotension. Cool skin may accompany arterial disease. Very warm skin may indicate a febrile state or hyperthyroidism.

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Dirty, broken, or jagged fingernails may be seen with poor hygiene. They may also result from the client's hobby or occupation.

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Blue-green fluorescence indicates fungal infection.

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Abnormal findings include rashes, such as the reddish (in light-skinned people) or darkened (in dark-skinned people) butterfly rash (also called malar rash) across the bridge of the nose and cheeks

Do skin problems limit any of your normal activities?

Allergens (poison oak, poison ivy) may limit certain activities such as hiking, camping, and gardening. Moreover, exposure to the sun can aggravate conditions such as scleroderma. In addition, general home maintenance (e.g., cleaning, car washing) may expose the client to certain cleaning products to which the client is sensitive or allergic.

Have you noticed any change in the general overall color of your skin?

An overall generalized change may indicate pallor, cyanosis, or jaundice suggestive of an underlying illness.

In your daily activities, are you regularly exposed to chemicals or irritants that may harm the skin (e.g., coal, tar, pitch, creosote, arsenic compounds, radium, alcohol, hand foam, latex, bleach, peroxide)?

Any of these substances and many others have the potential to irritate or damage the skin, hair, or nails and increase one's risk for skin cancer (for a list of the known and possible carcinogenic substances

Are you experiencing any current skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising, swelling, or changes in skin color? How long have you had this symptom? What aggravates the problem? What relieves it? Have you tried any over-the-counter remedies or been prescribed any medication for the problem?

Any of these symptoms may be related to a pathologic skin condition. It is important to find out what the client has tried and what has been effective or not. Swelling, bruises, welts, or burns may indicate accidents, trauma, or abuse. If these injuries cannot be explained or do not match the symptoms, or if the client's explanation seems unbelievable or vague, physical abuse should be suspected. Dry, pruritic skin, stretch marks, skin tags, dark patches, and skin infections are common in obese clients

OLDER ADULT CONSIDERATIONS

As people age, hair feels coarser and drier. The hair is also thinner with slower growth.

CULTURAL CONSIDERATIONS

Because of decreased sweat production, most Asians and Native Americans have mild to no body odor, whereas Whites and African Americans tend to have a strong body odor unless they use antiperspirant or deodorant products. Any strong body odor may indicate an abnormality

Have you noticed any change in your ability to feel pain, pressure, light touch, or temperature variations?

Changes in sensation or temperature may indicate vascular or neurologic problems such as peripheral neuropathy related to diabetes mellitus or arterial occlusive disease. Decreased sensation may put the client at risk for developing pressure injuries, impaired skin integrity, and skin infections.

While inspecting skin coloration, note any odors emanating from the skin.

Client has slight or no odor of perspiration, depending on activity.

Inspect for color variations. Inspect localized parts of the body, noting any color variation

Common variations include suntanned areas, freckles, or white patches known as vitiligo

Describe any previous problems with skin, hair, or nails, including any treatment or surgery and its effectiveness.

Current problems may be a recurrence of previous ones. Visible scars may be explained by previous problems.

CULTURAL CONSIDERATIONS

Dark-skinned clients may have thicker nails.

OLDER ADULT CONSIDERATIONS

Decreased flexibility and mobility may impair the ability of some elderly clients to maintain proper hygiene practices, such as nail cutting, bathing, and hair care. The products used may also be a cause of an abnormality. Certain soaps may be drying. It is preferable to apply lotions to moist or slightly wet skin. Improper nail-cutting technique can lead to ingrown nails or infection.

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Decreased turgor (a slow recoil or return of the skin to its normal state) is seen in dehydration. Recoil that occurs in less than 2 seconds suggests moderate dehydration, more than 2 seconds suggests severe dehydration, and more than 3 seconds is described as tenting.

Do you have a history of self-injury?

Dermatologic disorders and psychiatric conditions affect each other. Cutting or scratching the skin and skin breakouts and rashes often have an associated psychiatric condition. Anxiety and depression in and of themselves are not typically associated with skin issues. Self-injury, on the other hand, is classically associated with cutting, burning, scratching, piercing, carving, inserting objects under the skin, or hitting and pinching oneself, and is an unhealthy way to cope with emotional pain, intense anger, and frustration

abnormal

Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia (see Abnormal Findings 14-8). PALPATION

abormal

Erythema (skin redness and warmth) is seen in inflammation, allergic reactions, or trauma

CLINICAL TIP

Erythema in the dark-skinned client may be difficult to see. However, the affected skin feels swollen and warmer than the surrounding skin.

Do you have any birthmarks or moles? If so, please describe them. Have any of them changed color, size, or shape? Do you know how to check for the warning signs or characteristics (ABCDEs) of skin cancer?

Establishing normal or baseline data allows future variations to be detected. Multiple or atypical moles increase one's risk for skin cancer. A change in the appearance or bleeding of any skin lesion, especially a mole, may indicate cancer. Asymmetry, irregular borders, color variations, diameter greater than 1/4 in. or 6 mm and evolving or changing over time are characteristics of cancerous lesions. The Skin Cancer Foundation website shows images of skin cancer

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Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, or hepatic or renal failure. It may also result from chemotherapy or radiation therapy.

Do you sunbathe? What is the frequency and duration of sun or tanning-booth exposure? Do you use sun block and if so what type (specify SPF)?

Excessive or unprotected exposure to UVR can cause premature aging of skin and increase the risk of skin cancer. Hair can also be damaged by too much sun

abnormal

Excessive scaliness may indicate dermatitis. Raised lesions may indicate infections or tumor growth. Dull, dry hair may be seen with hypothyroidism and malnutrition. Poor hygiene may indicate a need for client education or assistance with activities of daily living. Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease

abnormal

For abnormal lesions, distribution may be diffuse (scattered all over), localized to one area, or in sun-exposed areas. Configuration may be discrete (separate and distinct), grouped (clustered), confluent (merged), linear (in a line), annular and arciform (circular or arcing), or zosteriform (linear along a nerve route) (see Abnormal Findings 14-7).

Have you had any recent hospitalizations or surgeries?

Hospitalization increases the client's risk for a hospital-acquired infection (HAI), such as methicillin-resistant Staphylococcus aureus (MRSA)

Do you perform skin self-examination once a month?

If clients do not know how to inspect the skin, teach them how to recognize suspicious lesions early

CLINICAL TIP

In the obese client, carefully inspect skin on the limbs, under breasts, and in the groin area where problems are frequent due to perspiration and friction.

abnormal

Indentations on the skin may vary from slight to great and may be in one area or all over the body.

CULTURAL CONSIDERATIONS

Individuals of Black African descent often have very dry scalps and dry, fragile hair, which the client may condition with oil or a petroleum jelly-like product. (This kind of hair is of genetic origin and not related to thyroid disorders or nutrition. Such hair needs to be handled very gently.)

CULTURAL CONSIDERATIONS

Individuals with fair complexions are at an increased risk for skin cancer.

Inspect general skin coloration. Keep in mind that the amount of pigment in the skin accounts for the intensity of color as well as hue.

Inspection reveals evenly colored skin tones without unusual or prominent discolorations.

Inspect general skin coloration. Keep in mind that the amount of pigment in the skin accounts for the intensity of color as well as hue.

Jaundice is characterized by yellow skin tones, ranging from pale to pumpkin, particularly of the sclera, oral mucosa, palms, and soles. Acanthosis nigricans (Fig. 14-3C) is velvety darkening of skin in body folds and creases, especially the neck, groin, and axilla.

abnormal

Jaundice is characterized by yellow skin tones, ranging from pale to pumpkin, particularly of the sclera, oral mucosa, palms, and soles. Acanthosis nigricans (Fig. 14-3C) is velvety darkening of skin in body folds and creases, especially the neck, groin, and axilla.

Do you have a family history of keloids?

Keloids are more common in skin of color (African, African-American, Asian descent) and in persons with a family history of keloids. Early studies indicate that keloids are more likely to form between ages 10 and 30, especially before age 18 Ear piercing, body piercing, surgical scarring, and other skin wounds cause keloid formation in genetically susceptible individuals.

If you suspect a fungus, shine a Wood light (a UV light filtered through a special glass) on the lesion.

Lesion does not fluoresce.

abnormal

Lesions may indicate local or systemic problems. Primary lesions (see Abnormal Findings 14-3) arise from normal skin due to irritation or disease. Secondary lesions (see Abnormal Findings 14-4) arise from changes in primary lesions. Vascular lesions (see Abnormal Findings 14-5), reddish-bluish lesions, are seen with bleeding, venous pressure, aging, liver disease, or pregnancy. Cancerous lesions can be either primary or secondary lesions and are classified as SCC, BCC, or malignant melanoma (see Abnormal Findings 14-6). See Abnormal Findings 14-6 for the use of the ABCDEs to detect signs of skin cancer.

Have you had any change in the condition or appearance of your nails? Describe.

Nail changes may be seen in systemic disorders such as malnutrition or with local irritation (e.g., nail biting). Bacterial infections cause green, black, or brown nail discoloration. Yellow, thick, crumbling nails are seen in fungal infections. Yeast infections cause a white color and separation of the nail plate from the nail bed. It takes 6 months to totally replace a fingernail and 12 months to totally replace a toenail.

Inspect nail grooming and cleanliness.

Nails are clean and manicured.

Palpate nail to assess texture.

Nails are hard and basically immobile.

Palpate to assess texture and consistency, noting whether nail plate is attached to nail bed.

Nails are smooth and firm; nail plate should be firmly attached to nail bed.

nspect the scalp and hair for general color and condition.

Natural hair color, as opposed to chemically colored hair, varies among clients from pale blond to black to gray or white. The color is determined by the amount of melanin present

If lesions are noted when assessing skin thickness, put gloves on and palpate the lesion between the thumb and index finger for size, mobility, consistency, and tenderness

No lesions palpated.

OLDER ADULT CONSIDERATIONS

Older clients have thinner hair because of a decrease in hair follicles. Pubic, axillary, and body hair also decrease with aging. Alopecia is seen, especially in men. Hair loss occurs from the periphery of the scalp and moves to the center.

OLDER ADULT CONSIDERATIONS

Older clients may have skin lesions associated with aging, including seborrheic or senile keratosis, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

OLDER ADULT CONSIDERATIONS

Older clients' nails may appear thickened, yellow, and brittle because of decreased circulation in the extremities.

OLDER ADULT CONSIDERATIONS

Older women may have terminal hair growth on the chin owing to hormonal changes.

Do you spend long periods of time sitting or lying in one position?

Older, disabled, or immobile clients who spend long periods of time in one position are at risk for impaired skin integrity

OLDER ADULT CONSIDERATIONS

The older client's skin loses its turgor because of a decrease in elasticity and collagen fibers. Sagging or wrinkled skin appears in the facial, breast, and scrotal areas.

abnormal

Pale or cyanotic nails may indicate hypoxia or anemia. Splinter hemorrhages may be caused by trauma. Beau lines occur after acute illness and eventually grow out. Yellow discoloration may be seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis (see Abnormal Findings 14-8).

CULTURAL CONSIDERATIONS

Pale or light-skinned clients have darker pigment around nipples, lips, and genitalia.

abnormal

Paronychia (inflammation) indicates local infection. Detachment of nail plate from nail bed (onycholysis) is seen in infections or trauma.

Have you had any hair loss, unusual increase in hair growth, or change in the condition of your hair? Describe.

Patchy hair loss (alopecia) may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy. (See Abnormal Findings 14-1, Common Hair Disorders). Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy. Certain medications can also contribute to hair loss. Also common with malabsorption syndromes, malnutrition, anorexia nervosa, and bulimia. Also common after gastric bypass surgery. Hair loss is common in aging. The rate of hair growth slows and hair strands become thinner. Some hair follicles stop producing hair. A receding hairline or male pattern baldness may occur with aging.

OLDER ADULT CONSIDERATIONS

Perspiration decreases with aging because sweat gland activity decreases.

Do you have any body piercings?

Piercing needles may place clients at risk for infection.

Test capillary refill in nail beds by pressing the nail tip briefly and watching for color change

Pink tone returns immediately to blanched nail beds when pressure is released.

Inspect nail color and markings.

Pink tones should be seen. Some longitudinal ridging is normal. Dark-skinned clients may have freckles or pigmented streaks in their nails.

Do you have trouble controlling body odor? Do you perceive yourself to have excessive perspiration?

Poor hygiene practices may account for body odor, and health education may be indicated. Uncontrolled body odor or excessive or insufficient perspiration (excessive perspiration: hyperhidrosis) may indicate an abnormality of the sweat glands or an endocrine problem such as hypothyroidism or hyperthyroidism.

Are you experiencing any pain, itching, tingling, or numbness?

Pruritus may be seen with dry skin, aging, drug reactions, allergies, lice, tinea, insect bites, uremia, or obstructive jaundice. Abnormal sensations of tingling, pricking, or burning are referred to as paresthesia. Numbness or dulling of the sensations of pain, temperature, and touch to the feet may be seen in diabetic peripheral neuropathy.

OLDER ADULT CONSIDERATIONS

The older client's skin may feel dryer than a younger client's skin because sebum production decreases with age.

What is your daily routine for skin, hair, and nail care? What products do you use (e.g., soaps, lotions, oils, cosmetics, self-tanning products, razor type, hair spray, shampoo, hair coloring, nail enamel)? How do you cut your nails?

Regular habits provide information on hygiene and lifestyle

Do you have any tattoos?

Risks involved with tattooing include infection, allergic reactions, formation of granulomas, keloid formation, swelling or burning sensations when undergoing magnetic resonance imagining (MRI) Also, tattoo removal is often painful and may cause scarring. Note that tattoos have been associated with hepatitis C infection. Clients should be informed regarding these risks.

CULTURAL CONSIDERATIONS

SLE prevalence is higher in Asians, African Americans, African Caribbeans, and Hispanics in the United States, but infrequent in Blacks in Africa (

At 1-in. intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions

Scalp is clean and dry. Sparse dandruff may be visible. Hair is smooth and firm, somewhat elastic.

CLINICAL TIP

Scarifications may be used by some individuals who want to have a scar or keloid. These scars involve cutting or sometimes burning of the skin to leave permanent scars

Do you recall having severe sunburns as a child?

Severe sunburns as a child are a risk factor for skin cancer

abnormal

Skin breakdown is initially noted as a reddened area on the skin that may progress to serious and painful pressure injuries (see Abnormal Findings 14-2 for stages of pressure injury development). Depending on the color of the client's skin, reddened areas may not be prominent, although the skin may feel warmer in the area of breakdown than elsewhere.

Assess skin integrity. Pay special attention to pressure point areas (Fig. 14-6). Use the Braden Scale (see Assessment Tool 14-2) to predict pressure sore risk

Skin is intact, and there are no reddened areas.

Palpate to assess temperature. Use the dorsal surfaces of your hands to palpate the skin

Skin is normally a warm temperature.

Palpate to assess thickness.

Skin is normally thin, but calluses (rough, thick sections of epidermis) are common on areas of the body that are exposed to constant pressure (e.g., the hee

Palpate skin to assess texture. Use the palmar surface of your three middle fingers to palpate skin texture.

Skin is smooth and even.

Inspect for lesions. Observe the skin surface to detect abnormalities. If you observe a lesion, • Note symmetry, borders, and shape, color, diameter of lesion, and change in lesion over time. • For very small lesions, use a magnifying glass to note these characteristics. • Note its location, distribution, and configuration. • Measure the lesion with a centimeter ruler.

Skin is smooth, without lesions. Stretch marks (striae), healed scars, freckles, moles, or birthmarks are common findings. Freckles or moles may be scattered over the skin in no particular pattern.

Palpate to detect edema. Use your thumbs to press down on the skin of the feet, ankles, or pretibial area to check for edema

Skin rebounds and does not remain indented when pressure is released.

Palpate to assess moisture. Check under skin folds and in unexposed areas.

Skin surfaces vary from moist to dry depending on the area assessed. Recent activity or a warm environment may cause increased moisture.

Describe any skin disorder that prevents you from enjoying your relationships.

Skin, hair, or nail problems, especially if visible, may impair the client's ability to interact comfortably with others because of embarrassment or perceived/actual rejection by others.

CULTURAL CONSIDERATIONS

Small amounts of melanin are common in pale or light skins, whereas large amounts of melanin are common in olive and darker skins. Carotene accounts for a yellow cast.

CULTURAL CONSIDERATIONS

Social stigma toward some dermatologic disorders is widespread. Dermatologic diseases are found to affect quality of life in many cultures, especially of females

Are you taking any medications (prescribed or "over the counter"), using any ointments or creams, herbal or nutritional supplements, or vitamins? If so, how long have you been taking each of these?

Some medications can cause a photosensitivity reaction if the skin is exposed to UV light. It often appears 24 hours after taking the medication and leaves after discontinuing the medication. Some clients may exhibit allergic skin reaction(s) to specific drugs, creams, or ointments.

CLINICAL TIP

Some nurses believe that using the dorsal surfaces of the hands to assess moisture leads to a more accurate result.

For female clients: Are you pregnant? Are your menstrual periods regular?

Some skin and hair conditions can result from hormonal imbalance.

Have you had a recent viral or bacterial illness?

Some skin rashes or lesions may be related to viruses or bacteria.

How much stress do you have in your life? Describe.

Stress can cause or exacerbate skin abnormalities.

Have you had any exposure to extreme temperatures?

Temperature extremes affect the blood supply to the skin and can damage the skin layers. Examples include frostbite and burns.

OLDER ADULT CONSIDERATIONS

The older client's skin becomes pale due to decreased melanin production and decreased dermal vascularity.

Inspect for color variations. Inspect localized parts of the body, noting any color variation

The variations are due to different amounts of melanin in certain areas. A generalized loss of pigmentation is seen in albinism. Dark-skinned clients have lighter colored palms, soles, nail beds, and lips. Freckle-like or dark streaks of pigmentation are also common in the sclera and nail beds of dark-skinned clients.

Inspect shape of nails.

There is normally a 160-degree angle between the nail base and the skin.

abnormal

There is slow (greater than 2 seconds) capillary nail bed refill (return of pink tone) with respiratory or cardiovascular diseases that cause hypoxia.

abnormal

Thickened nails (especially toenails) may be caused by decreased circulation and are also seen in onychomycosis.

CLINICAL TIP

To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.

Have you ever had any allergic skin reactions to food, medications, plants, or other environmental substances?

Various types of allergens can precipitate a variety of skin eruptions.

Inspect amount and distribution of scalp, body, axillae, and pubic hair. Look for unusual growth elsewhere on the body.

Varying amounts of terminal hair cover the scalp, axillae, body, and pubic areas according to normal gender distribution. Fine vellus hair covers the entire body except for the soles, palms, lips, and nipples. Normal male pattern balding is symmetric (Fig. 14-13). Individuals may shave or chemically remove axillary and genital hair. Some individuals, both male and female, may also remove all body hair.

Has anyone in your family had a recent illness, rash, or other skin problem or allergy? Describe.

Viruses (e.g., chickenpox, measles) can be highly contagious. Acne and atopic dermatitis tend to be familial. Some allergies may be identified from family history.

abnormal

characteristic of systemic lupus erythematosus (SLE). SLE is seen in a 9:1 female-to-male ratio and is more common in Black and Hispanic people

Inspect general skin coloration. Keep in mind that the amount of pigment in the skin accounts for the intensity of color as well as hue.

normal Inspection reveals evenly colored skin tones without unusual or prominent discolorations.