Ch 14 Assessing Skin, Hair, and Nails

Pressure ulcers

- Pressure ulcers are a major cause of morbidity and mortality. - The most significant contributing factor to pressure ulcer development is unrelieved pressure, but friction and shear also can contribute or worsen the condition. Prevalence of pressure ulcers varies by bed type and clinical area, but occur more frequently in critical care, long-term care facilities, and in patients at high risk, such as those on prolonged bed rest - However, a new device being developed by the U.S. Department of Veterans Affairs and General Electric may be successful at ending the problem of pressure ulcers in hospitals (U.S. Department of Veterans Affairs, 2015). Until such a device is developed, careful screening and prevention are needed.

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)

Braden Scale

for Predicting Pressure Ulcer Score Risk

Pressure point notes

- 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.

Dermis

- The inner layer of skin is the dermis - Dermal papillae connect the dermis to the epidermis. They are visible in the hands and feet, and create the unique pattern of friction ridges commonly known as fingerprints. - The dermis is a well-vascularized, connective tissue layer containing collagen, elastic fibers, nerve endings, and lymph vessels. - It is also the origin of sebaceous glands, sweat glands, and hair follicles.

Nails

- The nails, located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow from the cuticle - The nail body extends over the entire nail bed and has a pink tinge as a result of blood vessels underneath. - The lunula is a crescent-shaped area located at the base of the nail. - It is the visible aspect of the nail matrix. - The nails protect the distal ends of the fingers and toes, enhance precise movement of the digits, and allow for an extended precision grip.

moisture notes

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

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

Normal: - Client has slight or no odor of perspiration, depending on activity. Abnormal: - A strong odor of perspiration or foul odor may indicate disorder of sweat glands. Poor hygiene practices may indicate a need for client teaching or assistance with activities of daily living.

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 (Fig. 14-7). Observe for drainage or other characteristics.

Normal: - No lesions palpated. Abnormal: - Infected lesions may be tender to palpate. Nonmobile, fixed lesions may be cancer.

Sebaceous Glands

The sebaceous glands are attached to hair follicles and, therefore, are present over most of the body, excluding the soles and palms. They secrete an oily substance called sebum that waterproofs the hair and skin.

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 ulcers, impaired skin integrity, and skin infections.

Pressure Ulcer Stage 1

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones.

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

Normal: -Lesion does not fluoresce. Abnormal: - Blue-green fluorescence indicates fungal infection.

Older adults & skin lesions

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

Pressure Ulcer Stage 2

Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

Nail notes

- Dark-skinned clients may have thicker nails. - Older clients' nails may appear thickened, yellow, and brittle because of decreased circulation in the extremities.

Are you experiencing any current skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising, swelling, or changes in skin color? What aggravates the problem? What relieves it?

Any of these symptoms may be related to a pathologic skin condition. Swelling, bruises, welts, or burns may indicate accidents, trauma or abuse. If these injuries cannot be explained or do not match the symptoms, or 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

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

Normal: - Common variations include suntanned areas, freckles, or white patches known as vitiligo (Box 14-2). 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. Abnormal: - 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 (Fig. 14-5), 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

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

Normal: - Pink tone returns immediately to blanched nail beds when pressure is released. Abnormal: - Pink tone returns immediately to blanched nail beds when pressure is released.

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

Normal: - Skin is normally a warm temperature. Abnormal: - Cold skin may accompany shock or hypotension. Cool skin may accompany arterial disease. Very warm skin may indicate a febrile state or hyperthyroidism.

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

Pruritus may be seen with dry skin, 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.

Diseases and disorders of the skin, hair, and nails may be

local or caused by an underlying systemic condition

Use the Braden Scale to

predict pressure sore risk. If any skin breakdown is noted, use the PUSH tool (see Assessment Tool 14-2) to document the degree of skin breakdown to provide a baseline to compare degree of healing or deterioration over time.

The integumentary system consists of

the skin, hair, and nails, which are external structures that serve a variety of specialized functions. The sebaceous and sweat glands originating within the skin also have many vital functions. Each structure's function is described separately.

Hair notes

- As people age, hair feels coarser and drier. The hair is also thinner with slower growth. - 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.) - 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 women may have terminal hair growth on the chin owing to hormonal changes.

Subcutaneous Tissue

- Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles - The subcutaneous tissue stores fat as an energy reserve, provides insulation to conserve internal body heat, serves as a cushion to protect bones and internal organs, and contains vascular pathways for the supply of nutrients and removal of waste products to and from the 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 (ABCDE's) 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 inch or 6 mm and evolving or changing over time are characteristics of cancerous lesions

Hair

- Hair consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of the feet, palms of the hands, labia minora, and penis. Hair develops within a sheath of epidermal cells called the hair follicle. - Hair growth occurs at the base of the follicle, where cells in the hair bulb are nourished by dermal blood vessels. - The hair shaft is visible above the skin; the hair root is surrounded by the hair follicle - Attached to the follicle are the arrector pili muscles, which contract in response to cold or fright, decreasing skin surface area and causing the hair to stand erect (goose flesh).

Skin color notes

- Individuals with fair complexions are at an increased risk for skin cancer - Small amounts of melanin are common in pale or light skins, while large amounts of melanin are common in olive and darker skins. Carotene accounts for a yellow cast. - The older client's skin becomes pale due to decreased melanin production and decreased dermal vascularity.

The skin is the largest organ of the body.

- It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation (UVR), and dehydration. - It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. - The skin also provides individual identity to a person's appearance. The skin is thicker on the palms of the hands and soles of the feet, and is continuous with the mucous membranes at the orifices of the body. - It is composed of three layers: the epidermal, dermal, and subcutaneous tissue - Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

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

- Jaundice (Fig. 14-3B) 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.

Turgor notes

- Mobility refers to how easily the skin can be pinched. Turgor refers to the skin's elasticity and how quickly the skin returns to its original shape after being pinched. - 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.

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.

Pigmentation notes

- Pale or light-skinned clients have darker pigment around nipples, lips, and genitalia. - SLE prevalence is higher in Asians, Afro-Americans, Afro-Caribbeans, and Hispanics in the United States, but infrequent in blacks in Africa - Erythema in the dark-skinned client may be difficult to see. However, the affected skin feels swollen and warmer than the surrounding skin.

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

- Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy. 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 by-pass 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.

Epidermis

- The epidermis (Fig. 14-1B), the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. - The outermost layer consists of dead, keratinized cells that render the skin waterproof. (Keratin is a scleroprotein that is insoluble in water. - The epidermis, hair, nails, dental enamel, and horny tissues are composed of keratin.) The epidermal layer is almost completely replaced every 3 to 4 weeks. - The innermost layer of the epidermis (stratum germinativum) is the only layer that undergoes cell division and contains melanin (brown pigment) and keratin-forming cells. - The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.

General Routine Screening

- The nurse completes all of the general screening for all patients as indicated in the Assessment Procedure box below. Most often the nurse does not perform a total head to toe skin, nail, and scalp examination as would a dermatologist. Yet it is essential that all nurses know how to complete a total skin examination, how to teach the client to perform a skin self-examination, and how to collaborate with other health care professionals to clearly communicate skin findings. The nurse routinely inspects exposed skin areas for temperature, turgor, and edema when caring for the client. If a lesion is noted, further assessment is completed. If the nurse suspects that a client may be at risk for developing a pressure ulcer, the Braden scale should be used to assess the patient's degree of risk. Ordinarily the nurse would not use the PUSH Scale unless a skin ulcer was identified; then the nurse would use the PUSH Scale to further assess and document the degree of skin breakdown. - The nurse also routinely inspects the patient's nails for coloration and grooming. Nail changes are often a sign of other illnesses or conditions. For example, excessive nail biting may be a sign of anxiety. The color and condition of the hair is inspected. - In certain situations, the nurse performs a more detailed examination to include scalp inspection. For example, a school nurse may inspect and palpate the scalp in situations where head lice are suspected. Or if a client reports an extremely itchy, burning scalp, the nurse would inspect and palpate the scalp.

Sweat Glands

- The two types of sweat glands are eccrine and apocrine glands. - The eccrine glands are located over the entire skin. - Their primary function is secretion of sweat and thermoregulation, which is accomplished by evaporation of sweat from the skin surface. - The apocrine glands are associated with hair follicles in the axillae, perineum, and areolae of the breasts. - Apocrine glands are small and nonfunctional until puberty, at which time they are activated and secrete a milky sweat. - The interaction of sweat with skin bacteria produces a characteristic body odor. In women, apocrine secretions are linked with the menstrual cycle.

Skin cancer

- most common of cancers. It occurs in three types: melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). - BCC and SCC are nonmelanomas. Precursor lesions occur for some melanomas (benign or dysplastic nevi) and for invasive SCC (actinic keratoses or SCC in situ), but there are no precursor lesions for BCC. - Nonmelanocyte skin cancers are the most common worldwide and are also increasing in populations heavily exposed to sunlight, especially in areas of ozone depletion. - Malignant melanoma is the most serious skin cancer, and it is expected to account for 76,380 cases in 2016

There are two general types of hair:

- vellus and terminal - Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body. - Terminal hair (particularly scalp and eyebrows) is longer, generally darker, and coarser than vellus hair. - Puberty initiates the growth of additional terminal hair in both sexes on the axillae, perineum, and legs. - Hair color varies and is determined by the type and amount of pigment (melanin and pheomelanin) production. - A reduction in production of pigment results in gray or white hair. - Vellus hair provides thermoregulation by wicking sweat away from the body. Hair on the head protects the scalp, provides insulation, and allows for self-expression. - Nasal hair, auditory canal hair, eyelashes, and eyebrows filter dust and other airborne debris.

Pressure Ulcers

During any skin assessment, the nurse remains watchful for signs of skin breakdown, especially in cases of limited mobility or fragile skin (e.g., in elderly or bedridden clients). Pressure ulcers, which lead to complications such as infection, are easier to prevent than to treat. Some risk factors for skin breakdown leading to pressure ulcers include poor circulation, poor hygiene, infrequent position changes, dermatitis, infection, or traumatic wounds. The stages of pressure ulcers follow.

Pressure Ulcer unstageable

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.

Pressure Ulcer Stage 4

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomic location (see stage III). Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Pressure Ulcer Stage 3

Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

ASSESSMENT PROCEDURENORMAL FINDINGSABNORMAL FINDINGSSkinINSPECTION 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. Abnormal: - Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink. - Cyanosis may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Dark skin may appear blue, dull, and lifeless in the same areas. Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction.

Inspect nail grooming and cleanliness.

Normal: - Nails are clean and manicured. Abnormal: - Dirty, broken, or jagged fingernails may be seen with poor hygiene. They may also result from the client's hobby or occupation.

Palpate nail to assess texture.

Normal: - Nails are hard and basically immobile. Abnormal: - Thickened nails (especially toenails) may be caused by decreased circulation, and are also seen in onychomycosis.

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

Normal: - Nails are smooth and firm; nail plate should be firmly attached to nail bed. Abnormal: - Paronychia (inflammation) indicates local infection. Detachment of nail plate from nail bed (onycholysis) is seen in infections or trauma.

Inspect the scalp and hair for general color and condition.

Normal: - 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. Abnormal: - Nutritional deficiencies may cause patchy gray hair in some clients. Severe malnutrition in African American children may cause a copper-red hair color

Palpate to assess mobility and turgor. Ask the client to lie down. Using two fingers, gently pinch the skin over the clavicle.

Normal: - Normally, the skin is mobile, with elasticity and returns to original shape quickly. Recoil is usually immediate. Abnormal: - Decreased mobility is seen with edema. - 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.

Inspect nail color and markings.

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

At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions (Fig. 14-10). Wear gloves if lesions are suspected or if hygiene is poor.

Normal: - Scalp is clean and dry. Sparse dandruff may be visible. Hair is smooth and firm, somewhat elastic. 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 teaching or assistance with activities of daily living. Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease (ringworm, Fig. 14-11). Infections of the hair follicle (folliculitis) appear as pustules surrounded by erythema (Fig. 14-12).

Assess skin integrity. Pay special attention to pressure point areas

Normal: - Skin is intact, and there are no reddened areas. Abnormal: - Skin breakdown is initially noted as a reddened area on the skin that may progress to serious and painful pressure ulcers (see Abnormal Findings 14-1 for stages of pressure ulcer 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.

Palpate to assess thickness.

Normal: - 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 heels). Abnormal: Very thin skin may be seen in clients with arterial insufficiency or in those on steroid therapy.

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

Normal: - Skin is smooth and even. Abnormal: - Rough, flaky, dry skin is seen in hypothyroidism. Obese clients often report dry, itchy skin.

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.

Normal: - 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. Abnormal: Lesions may indicate local or systemic problems. Primary lesions (see Abnormal Findings 14-2) arise from normal skin due to irritation or disease. Secondary lesions (see Abnormal Findings 14-3) arise from changes in primary lesions. Vascular lesions (see Abnormal Findings 14-4), 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 squamous cell carcinoma, basal cell carcinoma, or malignant melanoma (see Abnormal Findings 14-5).

Palpate to detect edema. Use your thumbs to press down on the skin of the feet, ankles, or pretibial area to check for edema (swelling related to accumulation of fluid in the tissue).

Normal: - Skin rebounds and does not remain indented when pressure is released. Abnormal: - Indentations on the skin may vary from slight to great and may be in one area or all over the body.

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

Normal: - Skin surfaces vary from moist to dry depending on the area assessed. Recent activity or a warm environment may cause increased moisture. Abnormal: - Increased moisture or diaphoresis (profuse sweating) may occur in conditions such as fever or hyperthyroidism. Decreased moisture occurs with dehydration or hypothyroidism. Clammy skin is typical in shock or hypotension.

Inspect shape of nails.

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

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

Normal: - 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. Abnormal: - Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure. It may also result from chemotherapy or radiation therapy. - Patchy hair loss (Fig. 14-14) may result from infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy. - Hirsutism (facial hair on females) is a characteristic of Cushing disease and polycystic ovary syndrome (PCOS) and results from an imbalance of adrenal hormones or it may be a side effect of steroids (Mayo Clinic, 2015a).

Notes

Older adult considerations: - Perspiration decreases with aging because sweat gland activity decreases. Cultural considerations: - Because of decreased sweat production, most Asians and Native Americans have mild to no body odor, whereas Caucasians 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

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 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.