Assessment of Skin, Hair, and Nails

Common Elderly Skin Changes

-pigment changes -decreased secretion of sebaceous glands (drier skin) -decreased elasticity (can be related to hydration as well) -decreased blood vessels -decreased touch receptors -decreased wound healing -increased petechiae

Determining Malignancy of Melanoma

-symmetry -even or uneven borders -one or 2+ shades -size (benign: smaller than 1/4 inch OFTEN)

Turgor

Elasticity of the skin

Redness or erythema of the skin is often related to what?

INFLAMMATION

What intervention is implemented for milia in newborns?

NONE -normal skin condition after birth

Ecchymosis

bruises -large areas of bleeding associated with injury -may be caused by: medications (aspirin, warfarin, corticosteroids), low platelets, clotting disorders

What do "Mongolian" spots on a newborn resemble?

bruising (child abuse allegations are often made) -BE SURE TO DOCUMENT THIS IN CHART: avoid false allegations of abuse

Clubbing of Nails

bulbous swelling of soft tissue of terminal phalanx of a digit

To differentiate between color changes from underlying vascular supply problems and those resulting from pigment deposition assess ________________ ______________.

capillary refll

Blue or cyanosis of the skin is often related to what?

cardiopulmonary diseases or the end of life

What sort of issues lead to clubbing?

cardiopulmonary issues

Anatomy of the Hair

cells of the germinal matrix responsible for forming hairs these cells undergo repeated mitsos, push upward in the follicle and become keratinized to form hair

Inspection of Scalp

check for scaling, redness, open areas, crusting, & tenderness

What may trigger changes in color to the nails?

chemical damage that occurs with some occupations long-term use of nail polish/acrylic nails

What sort of patient population often has Beau Lines present in nails?

chemotherapy patients or patients with severe, sudden, acute illness

Circunate

circular

Annular

circular, ring-shaped raised border around normal skin

Inspecting and Palpating the Hair

cleanliness: may confirm for mental status/health care needs distribution quantity quality

Transmission of Head Lice

close personal contact contact with clothing, hairbrushes, and furniture (etc.) CANNOT be acquired through contact with pets or other animals

Dandruff

collection of patchy or diffuse white and gray scales on the surface of the scalp -caused by excessive *OIL production* -cosmetic issue (in most cases)

What features do you assess during inspection and palpation of the skin?

color or presence of lesions moisture temperature texture/thickness turgor vascularity edema pain response (with palpation)

Pigment Alterations of Nails

color remains UNCHANGED with OR without pressure

Assessment of Fingernails

color, shape, thickness, texture, presence of lesions

Assessment of Lesions

color: consistent vs. variegated location on body texture: smooth/scaly size in mm/cm shape: symmetry elevation or pedunculation distribution pattern or grouping drainage/exudate: amount, color, odor pruritic

Piercing Medical Complications

common metal-induced contact allergic dermatitis broken teeth anesthetic risks and infections

Cherry (senile) hemangiomas

common and arise in middle-aged to older adults -a *vascular* lesion

Skin Color Change: BLUE (cyanosis)

condition: Hypoxia cause: heart, lung, cold assessment location: nails, lips, mouth, skin

Skin Color Change: Tan or Brown

condition: increased melanin cause: suntan or pregnancy (PG) assessment location: sun exposed skin or areolas/nipples

Skin Color Change: Red (erythema)

condition: increased visibility of Hgb cause: fever, trauma, blushing, ETOH assessment location: skin

Skin Color Change: Pallor (PALE)

condition: low Hhb or altered circulation cause: anemia or shock assessment location: face, conjunctivae, nails, palms, skin

Skin Color Change: Pigment Loss

condition: vitiligo cause: congenital or autoimmune assessment location: patchy on the skin of face, arms, or hands

Squamous Cell Carcinoma

crusty, flaky look

Etiology of Beau Lines

damage to the matrix -caused by severe/sudden/acute illnesses or reactions to certain drugs (like chemotherapy)

Linea nigra

darkened line from umbilicus to symphysis pubis -darkening of areola is also common -usually fades after birth

Chloasma

darker pigmentation on the forehead, nose, and cheeks *during pregnancy* -"the mask of pregnancy" -usually fades after birth

Age-Related Skin Changes: Sebaceous Glands

decrease in size, number, and output

What causes an increase in wrinkles in the elderly population?

decreased elastin and subcutaneous tissue

Age-Related Skin Changes: Sweat Glands

decreased output

Onycholysis

detachment of nail from its bed at the distal and/or lateral attachments

Layers of Skin

epidermis, dermis, hypodermis

Intense Itching or Scratching of Hair

examine scalp and pubis for lice and nits (lice eggs)

Causes of Hirsutism

excess male hormones (androgens) *primarily: testosterone*

Where are skin tags frequently located on the body?

eyelids cheeks and neck axilla and trunk

Ephelides

freckles small light brown *macules* on sun-exposed skin of fair-skinned people -appear in early childhood and often regress in later life

Common Type of Baldness

genes for baldness + male sex hormones (androgens)

How do you assess *turgor* in patients?

gently pinch the skin and release -normal: skin immediately returns to original state -poor skin turgor: "tenting" of skin with slow return to normal

What PPE might you use while assessing patient's skin?

gloves

Age-Related Nail Changes

gradual thickening of the nail plate LONGITUDINAL ridges yellowish or gray discoloration

Clustered

grouped together

Appendages of Skin

hair follicles sebaceous and sweat glands nails

Severe Inflammatory Dandruff

hair loss may occur if left untreated -teach patient that dandruff is NOT caused by dryness and should be treated to prevent hair loss

Etiology of Onycholysis

idiopathic mechanical or chemical damage associated with psoriasis

Skin Color Change: Yellow-Orange

indicates *jaundice* condition: elevated bilirubin cause: liver disease or destroyed RBCs assessment location: sclera, skin, mucus membranes

Pediculosis

infestation with any of several kinds of lice

Primary Lesion

initial sign of pathological process

When assessing the skin, what steps of IPPA do you accomplish simultaneously?

inspection & palpation

Onychomycosis

invasion of the nail by FUNGUS -affects up to 14% of the population (increasing prevalence among older individuals)

What does damage or trauma to the LUNULA cause?

irregular nail growth

Melanoma

irregular, asymmetrical, different colors

pruritic

itching

Secondary Lesion

later formation AFTER trauma to primary lesion

Coalesced

lesions that merge together

Cyanosis in Dark Skin

lips/tongues: grayish palms, soles, conjunctivae, and nail beds will have blue tinge -other indicators of hypoexmia should be assessed

Skin varies greatly in thickness largely depending on ________________ of the body.

location

Age-Related Hair Changes

looks gray or white *due to decrease in number of functional melanocytes* -sudden asymmetric or patchy hair loss at any age is a concern

Vitiligo

loss of pigment in areas of the skin -may be congenital OR autoimmune

Schamroth Sign

loss of the diamond shape formed when the right & left thumbs are opposed in a person -positive = present (abnormal) -negative = no clubbing

What causes pallor?

lowered Hgb content fight or flight response medications (Vasopressors) cold shock

Androgenic Alopecia

male or female pattern baldness

Hirsutism

male-pattern hair growth in women -excessive amounts of stiff, pigmented hair on body areas where men typically grow hair: face/chest/back

"Stork Bite"

nervus simplex caused by the dilation of small capillaries regress spontaneously

Erythema toxicum

newborn rash; transient maculopapular rash -may be caused by: increased *eosinophil activity*

Mongolian Spots

newborns normal in *dark-skinned infants* -fade during 1st few years of life

Characteristics of Purpura and Petechiae

non-blanching petechiae: 1-3 mm (flat, pinpoint) purpura are generally larger

Body Area

observe areas of tattooing and piercing for infection & inflammation -tattooing medical complications are rare: often related to pigment ingredients (may include viral/bacterial/fungal or diseases)

Pallor Changes

observed most readily in the: palms nail beds face conjunctivae

Purpura & Petechiae

often due to low platelets OR clotting disorders causing *increased capillary fragility*

Skin Tags

overgrowths of normal skin that forms a stalk (pedunculated) -more common with diabetes

Erythema in Dark Skin

palpate for a *temperature difference*

Types of Life Encountered Most Frequrntly

pediculus humanus capitis (head louse) pediculus human corporis (body louse) Phthirus pubis (pubic or crab lice)

Nail Plate

pink color from vascular nail bed beneath

Anatomy of Nails

protects the distal ends of fingers and toes

Wheal

raised bump in skin -like TB test

Louse

require blood; feed many times/day causes pruritus (result of sensitization to louse saliva) scratching may cause secondary bacterial infections

Pruritus

severe itching

What is an abnormal assessment finding in patient skin turgor?

skin "tenting" with slow return to normal

Normal Nail Characteristics

slightly curved or flat smooth clean translucent lighter nail base (see-through --> capillary refill)

Weeping Edema

small fluid leak occurs at point where pressure applied

Purpuric Lesions

small vessels that burst WITHOUT trauma or injury

Linear

straight line

Transient

temporary, will go away on its own

Vascular Alterations of Nails

the color will change as pressure is applied & returns to the original state when releases

Nail Matrix

the site of growth; protected by cuticle

What is an important consideration in assessing variations in skin color?

the surface area AND location of color change -localized vs. generalized

Where are cherry (Senile) hemangiomas usually located on the body?

the trunk -increase in size/number with aging -benign

Color of Nail Plate Depends on

thickness transparency amount of red blood cells arterial blood flow pigment deposits

Beau Lines

transverse band-like depressions in the nail

When measuring lesions, what should you avoid?

"dime-sized" measure in mm or cm

Actinic lentigo

"liver spots" normal with aging *clusters of melanocytes* on the dorsa of hands/forearms

What is key to assessing patients with darker skin tones?

assessment in *Good lighting* adequate assessment of the mucous membranes (PALLOR)

pedunculation

attached like a skin tage

Regardless of skin color, what assessment can be done to assess nails?

a healthy nail *blanches* with pressure

Cafe-au-Lait

a light brown oval *macule* (dark brown or brown or black skin) found ANYWHERE on the body -persist throughout life -may increase in number with age

Skin

a window for viewing changes that take place within the body

Dystrophic

abnormal nails may occur with serious systemic illness or local skin disease involving the epidermal keratinocytes

Skin and Mucous Membrane Color Determinations

affected by: melanin carotene oxyhemoglobin (Hgb) deoxhyhemoglobin (Hhb) bilirubin

Senile Xerosis

age-related DRY SKIN -itchy -flaky, loose appearing

What causes longitudinal ridges in the nails?

age-related nail changes

What indicates skin turgor caused by aging vs skin turgor caused by dehydration?

aging: hydration issues:

Universal

all over with no "normal" skin

Lesion

any unusual finding on the skin surface

Process of Hair Growth

as long as the cells of the germinal matrix remain alive, hair regenerates even though it is cut/plucked/removed

What medications sometimes cause ecchymosis of the skin?

aspirin warfarin corticosteroids

What do sudden or marked changes in hair characters reflect?

underlying disease processes

Milia

unopened or clogged sebacous glands that usually appear on *newborn nose or cheeks*

Pallor in Dark Skin

use good lighting mucous membranes: ash-gray color absence of underlying red tones

Carter Skin Lesion Assessment Tree

used to differentiate lesions of the skin

What can alter turgor?

water content aging

Circumscribed

well-defined borders

Lunula

white crescent-shaped area that extends beyond cuticle the visible portion of the nail matrix

Diffuse

wide-spread generalized