1. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Skin, Hair, and Nails Chapter 12

2. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Structure and Function  Think of skin as body’s largest organ system  Covers 20 square feet of surface area in adults  Skin is sentry that guards body Environmental stresses, e.g., trauma, pathogens, dirt Environmental stresses, e.g., trauma, pathogens, dirt Adapts it to other environmental influences, e.g., heat, cold Adapts it to other environmental influences, e.g., heat, cold Slide 12-2

3. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Structure and Function (cont.)  Skin has two layers:  Epidermis: outer highly differentiated layer Basal cell layer forms new skin cells Basal cell layer forms new skin cells Outer horny cell layer of dead keratinized cells Outer horny cell layer of dead keratinized cells  Derivation of skin color  Dermis: inner supportive layer Connective tissue or collagen Connective tissue or collagen Elastic tissue Elastic tissue  Beneath these layers is a subcutaneous layer of adipose tissue Slide 12-3

4. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Structure of Skin Slide 12-4

5. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Structure and Function (cont.)  Epidermal appendages:  Structures formed by tubular invagination of epidermis down into underlying dermis  Hair  Sebaceous glands  Sweat glands: important for fluid balance and thermoregulation Eccrine glands Eccrine glands Apocrine glands Apocrine glands  Nails Slide 12-5

6. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Structure of Nails Slide 12-6

7. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Structure and Function (cont.)  Skin is waterproof, protective, and adaptive  Protection from environment  Prevents penetration  Perception  Temperature regulation  Identification  Communication  Wound repair  Absorption and excretion  Production of vitamin D Slide 12-7

8. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Subjective Data  Health History Questions  Past history of skin disease, allergies, hives, psoriasis, or eczema?  Change in pigmentation or color?  Change in mole size, shape, color, tenderness?  Excessive dryness or moisture?  Pruritus or skin itching?  Excessive bruising?  Rash or lesions?  Medications: prescription and over-the-counter? Slide 12-8

9. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Subjective Data (cont.)  Health History Questions (cont.)  Hair loss?  Change in nails’ shape, color, or brittleness?  Environmental or occupational hazards?  Self-care behaviors? Slide 12-9

10. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Subjective Data (cont.)  Additional history for infants and children  Does child have any birthmarks?  Any change in skin color as a newborn? Physiologic jaundice? Physiologic jaundice? Cyanosis? Cyanosis?  Does child have any rash or sores?  Does child have diaper rash?  Does child have any burns or bruises? Where? Where? How did it happen? How did it happen? Slide 12-10

11. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Subjective Data (cont.)  Additional history for infants and children (cont.)  Has child been exposed to: Contagious skin conditions: scabies, impetigo, lice? Contagious skin conditions: scabies, impetigo, lice? Communicable diseases: measles, chicken pox, scarlet fever? Communicable diseases: measles, chicken pox, scarlet fever? Toxic plants: poison ivy? Toxic plants: poison ivy?  Does child have habits such as nailbiting or twisting hair?  What steps are taken to protect child from sun exposure? Slide 12-11

12. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Subjective Data (cont.)  Additional history for adolescents  Skin problems such as pimples, blackheads?  Additional history for aging adults  What changes have you noticed in your skin in last few years?  Any delay in wound healing?  Any change in feet: toenails; bunions, wearing shoes?  Falling: bruises, trauma?  History of diabetes or peripheral vascular disease? Slide 12-12

13. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination  Preparation  Consciously attend to skin characteristics; the danger is one of omission  Equipment needed  Strong direct lighting, gloves, penlight, and small centimeter ruler  For special procedures Wood’s light Wood’s light Magnifying glass Magnifying glass Materials for laboratory tests: potassium hydroxide (KOH) and glass slide Materials for laboratory tests: potassium hydroxide (KOH) and glass slide Slide 12-13

14. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Complete Physical Examination  Skin assessment integrated throughout examination  Scrutinize the outer skin surface first before you concentrate on underlying structures  Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin and inspect them thoroughly These areas are dark, warm, and moist and provide perfect conditions for irritation or infection These areas are dark, warm, and moist and provide perfect conditions for irritation or infection  Always inspect feet, toenails, and between toes Slide 12-14

15. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Regional Examination  Individuals may seek health care for skin problems and assessment focused on skin alone  Assess skin as one entity; getting overall impression helps reveal distribution patterns  Inspect lesions carefully  With a rash, check all areas of body as you cannot rely on the history that rash is in only one location  Skills used are inspection and palpation because some skin changes have accompanying signs that can be felt Slide 12-15

16. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Inspect and palpate skin  Color General pigmentation, freckles, moles, birthmarks General pigmentation, freckles, moles, birthmarks Widespread color change Widespread color change  Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow)  Note if color change transient or due to pathology Slide 12-16

17. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Inspect and palpate skin (cont.)  Temperature Use backs of hands to palpate person Use backs of hands to palpate person Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status Hands and feet may be slightly cooler in a cool environment Hands and feet may be slightly cooler in a cool environment  Hypothermia  Hyperthermia  Moisture Diaphoresis Diaphoresis Dehydration Dehydration Slide 12-17

18. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Inspect and palpate skin (cont.)  Texture  Thickness  Edema  Mobility and turgor  Vascularity or bruising Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein Slide 12-18

19. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Inspect and palpate skin (cont.)  Lesions: if any are present note: Color Color Elevation Elevation Pattern or shape Pattern or shape Size Size Location and distribution on body Location and distribution on body Any exudate: note color and odor Any exudate: note color and odor Use a Wood’s light (ultraviolet light filtered through special glass) to detect fluorescing lesions Use a Wood’s light (ultraviolet light filtered through special glass) to detect fluorescing lesions Slide 12-19

20. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Inspect and palpate hair  Color  Texture  Distribution  Lesions Slide 12-20

21. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Inspect and palpate nails  Shape and contour Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees  Consistency  Color  Capillary refill Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation Color return is normally instant Color return is normally instant Sluggish color return takes longer than 1 or 2 seconds Sluggish color return takes longer than 1 or 2 seconds Slide 12-21

22. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Objective Data: Physical Examination (cont.)  Promoting health and self-care  Teach skin self-examination using ABCDE rule to detect suspicious lesions A - asymmetry A - asymmetry B - border B - border C - color C - color D - diameter D - diameter E - elevation and enlargement E - elevation and enlargement Slide 12-22

23. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings  Shapes and configurations of lesions  Annular or circular  Confluent  Discrete  Grouped  Gyrate  Target or iris  Linear  Polycyclic  Zosteriform Slide 12-23

24. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Annular or Circular Slide 12-24

25. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Confluent Slide 12-25

26. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Discrete Slide 12-26

27. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Gyrate Slide 12-27

28. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Grouped Slide 12-28

29. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Linear Slide 12-29

30. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Target Slide 12-30

31. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Zosteriform Slide 12-31

32. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Polycyclic Slide 12-32

33. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.) Primary skin lesions  Macules  Papules  Patches  Plaques  Nodules  Wheals  Tumors  Urticaria (hives)  Vesicles  Cysts  Bullas  Pustules Slide 12-33

34. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Macule Slide 12-34

35. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Papule Slide 12-35

36. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Nodule Slide 12-36

37. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Wheal Slide 12-37

38. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Vesicle/Bulla Slide 12-38

39. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Cyst Slide 12-39

40. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Pustule Slide 12-40

41. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.) Secondary skin lesions  Debris on skin surface  Crusts  Scales  Break in continuity of skin surface  Fissures  Erosions  Ulcers  Excoriations  Scars  Atrophic scars  Lichenifications  Keloids Slide 12-41

42. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Crust Slide 12-42

43. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Scale Slide 12-43

44. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Fissure Slide 12-44

45. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Erosion Slide 12-45

46. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Ulcer Slide 12-46

47. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Excoriation Slide 12-47

48. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Scar Slide 12-48

49. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Atrophic Scar Slide 12-49

50. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Lichenification Slide 12-50

51. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Keloid Slide 12-51

52. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.) Vascular Lesions  Hemangiomas  Port-wine stain (nevus flammeus)  Strawberry mark (immature hemangioma)  Cavernous hemangioma (mature)  Telangiectases  Spider or star angioma  Venous lake  Purpuric lesions  Petechiae  Purpura  Lesions caused by trauma or abuse  Pattern injury  Hematoma  Contusion (bruise) Slide 12-52

53. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Lesions Caused by Trauma or Abuse: Pattern Injuries Slide 12-53

54. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Lesions Caused by Trauma or Abuse: Hematomas Slide 12-54

55. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Lesions Caused by Trauma or Abuse: Contusions Slide 12-55

56. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.)  Common skin lesions in children  Diaper dermatitis  Interigo (candidiasis)  Impetigo  Atopic dermatitis (eczema)  Measles (rubeola)  German measles (rubella)  Chickenpox (varicella) Slide 12-56

57. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.)  Common skin lesions  Primary contact dermatitis  Allergic drug reaction  Tinea corporis (ringworm of the body)  Tinea pedis (ringworm of the foot)  Psoriasis  Tinea versicolor  Labial herpes simplex (cold sores)  Herpes zoster (shingles)  Erythema migrans of Lyme disease Slide 12-57

58. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.)  Malignant skin lesions  Basal cell carcinoma  Squamous cell carcinoma  Malignant melanoma  Metastic malignant melanoma Slide 12-58

59. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.)  Skin lesions associated with AIDS  AIDS-related Kaposi’s sarcoma A vascular tumor is most common tumor in persons infected with HIV A vascular tumor is most common tumor in persons infected with HIV Considered an AIDS-defining illness Considered an AIDS-defining illness Can occur at any stage of HIV infection Can occur at any stage of HIV infection Slide 12-59

60. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.) Abnormal conditions of hair  Seborrheic dermatitis (cradle cap)  Tinea capitis (scalp ringworm)  Toxic alopecia  Alopecia areata  Traumatic alopecia, traction alopecia  Trichotillomania  Pediculosis capitis (head lice)  Folliculitis  Hirsutism  Furuncle and abscess Slide 12-60

61. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 12: Skin, Hair, and Nails Abnormal Findings (cont.)  Abnormal conditions of nails  Scabies  Paronychia  Beau’s line  Splinter hemorrhages  Late clubbing  Onycholysis  Pitting  Habit-tic dystrophy Slide 12-61