Jarvis Chapter 12

Front 1

Observe the skin tone. Normally it is consistent with genetic background and varies from pinkish tan to ruddy dark tan or from light to dark brown and may have yellow or olive overtones. Dark-skinned people normally have areas of lighter pigmentation on the palms, nail beds, and lips

Back 1

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 (Fig. 12-3, B). Vitiligo can occur in all races, although dark-skinned people are more severely affected and potentially suffer a greater threat to their body image.

Front 2

Freckles (ephelides)

Back 2

small, flat macules of brown melanin pigment that occur on sun-exposed skin

Front 3

Mole (nevus)

Back 3

a proliferation of melanocytes, tan to brown color, flat or raised. Acquired nevi are characterized by their symmetry, small size (6 mm or less), smooth borders, and single uniform pigmentation. The junctional nevus (Fig. 12-4, B) is macular only and occurs in children and adolescents. It progresses to the compound nevi in young adults (Fig. 12-4, C) that are macular and papular. The intradermal nevus (mainly in older age) has nevus cells in only the dermis.

Front 4

Birthmarks

Back 4

may be tan to brown in color.

Front 5

General pigmentation is darker in sun-exposed areas. Common (benign) pigmented areas also occur:

Back 5

Abnormal Findings

Danger signs: abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE:

Asymmetry, (not regularly round or oval, two halves of lesion do not look the same)

Border irregularity (notching, scalloping, ragged edges or poorly defined margins)

Color variation (areas of brown, tan, black, blue, red, white, or combination)

Diameter greater than 6 mm (i.e., the size of a pencil eraser), although early melanomas may be diagnosed at a smaller size (Oliviero, 2002).

Elevation and Enlargement

Additional symptoms: change in mole's size, a new pigmented lesion, and development of itching, burning, or bleeding in a mole. Any of these signs should raise suspicion of malignant melanoma and warrant referral.

Front 6

Widespread Color Change

Back 6

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 if it is due to pathology.

In dark-skinned people the amount of normal pigment may mask color changes. Lips and nail beds show some color change, but they vary with the person's skin color and may not always be accurate signs. The more reliable sites are those with the least pigmentation, such as under the tongue, the buccal mucosa, the palpebral conjunctiva, and the sclera. See Table 12-2 on pp. 249 and 250 for specific clues to assessment.

Front 7

Pallor

Back 7

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.

Front 8

Pallor

Back 8

Rationale

Ashen gray color in dark skin or marked pallor in whites occurs with anemia, shock, arterial insufficiency (see Table 12-2, p. 249).
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Front 9

Pallor

Back 9

Look for pallor in dark-skinned people by the absence of the underlying red tones that normally give brown or black skin its luster. The brown-skinned individual demonstrates pallor with a more yellowish-brown color, and the black-skinned person will appear ashen or gray. Generalized pallor can be observed in the mucous membranes, lips, and nail beds. The palpebral conjunctiva and nail beds are preferred sites for assessing the pallor of anemia. When inspecting the conjunctiva, lower the lid sufficiently to visualize the conjunctiva near the outer canthus as well as the inner canthus. The coloration is often lighter near the inner canthus.

Front 10

Pallor

Back 10

Abnormal Findings

The pallor of impending shock is accompanied by other subtle manifestations, such as increasing pulse rate, oliguria, apprehension, and restlessness.

Anemias, particularly chronic defiiron ciency anemia, may show “spoon” nails, with a concave shape. A lemon yellow tint of the face and slightly yellow sclera accompany pernicious anemia, also indicated by neurologic deficits and a red, painful tongue. Fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function accompany most severe anemias.

Front 11

Erythema is an intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries. This sign is expected with fever, local inflammation, or with emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest).

Back 11

Abnormal Findings

Erythema occurs with polycythemia, venous stasis, carbon monoxide poisoning, and the extravascular presence of red blood cells (petechiae, ecchymosis, hematoma)(see Tables 12-2 and 12-7).

Front 12

Erythema

Back 12

When erythema is associated with fever or localized inflammation, it is characterized by increased skin temperature from the increased rate of blood flow through the blood vessels. Because you cannot see inflammation in dark-skinned persons, it is often 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.

Front 13

This is a bluish mottled color that signifies decreased perfusion; the tissues are not adequately perfused with 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 is unable to 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.

Back 13

Abnormal Findings

Cyanosis indicates hypoxemia and occurs with shock, heart failure, chronic bronchitis, and congenital heart disease

Front 14

Cyanosis

Back 14

Cyanosis is difficult to observe in darkly pigmented persons (see Table 12-2). 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.

Front 15

Jaundice is exhibited by a yellow color, indicating rising amounts of bilirubin in the blood. Except for physiological jaundice in the newborn (p. 240), 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.

Back 15

Abnormal Findings

Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn.

Front 16

Jaundice is exhibited by a yellow color, indicating rising amounts of bilirubin in the blood. Except for physiological jaundice in the newborn (p. 240), 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.

Back 16

Abnormal Findings

Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn.

Front 17

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.

Back 17

Abnormal Findings

Light or clay-colored stools and dark golden urine often accompany jaundice in both light- and dark-skinned people.

Front 18

Temperature

Back 18

Note the temperature of your own hands. Then use the backs (dorsa) of your hands to palpate the person and check bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. Hands and feet may be slightly cooler in a cool environment.

Front 19

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.

Back 19

Abnormal Findings

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

Front 20

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.

Back 20

Abnormal Findings

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

Front 21

Perspiration appears normally on the face, hands, axilla, and skinfolds in response to activity, a warm environment, or anxiety. Diaphoresis, or profuse perspiration, accompanies an increased metabolic rate, such as occurs in heavy activity or fever.

Back 21

Abnormal Findings

Diaphoresis occurs with thyrotoxicosis and with stimulation of the nervous system with anxiety or pain.

Front 22

Look for dehydration in the oral mucous membranes. Normally there is none, and the mucous membranes look smooth and moist. Be aware that dark skin may normally look dry and flaky, but this does not necessarily indicate systemic dehydration

Back 22

Abnormal Findings

With dehydration, mucous membranes look dry and the lips look parched and cracked. With extreme dryness the skin is fissured, resembling cracks in a dry lake bed.

Front 23

Texture

Normal skin feels smooth and firm, with an even surface.

Back 23

Abnormal Findings

Hyperthyroidism—skin feels smoother and softer, like velvet.

Hypothyroidism—skin feels rough, dry, and flaky.

Front 24

Thickness

The epidermis is uniformly thin over most of the body, although thickened callus areas are normal on palms and soles. A callus is a circumscribed overgrowth of epidermis and is an adaptation to excessive pressure from the friction of work and weight bearing.

Back 24

Abnormal Findings

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

Front 25

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 indentation, no perceptible swelling of the leg

2+ Moderate pitting, indentation subsides rapidly

3+ Deep pitting, indentation remains for a short time, leg looks swollen

4+ Very deep pitting, indentation lasts a long time, leg is very swollen

This scale is somewhat subjective; outcomes vary among examiners (see further content on grading scale in Chapter 20).

Edema masks normal skin color and obscures pathological 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.
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Back 25

Abnormal Findings

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 pig-skin 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.

Front 26

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.

Back 26

Abnormal Findings

Mobility is decreased when edema is present.

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 (see Table 13-4, p. 297).

Front 27

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

Any bruising (ecchymosis) should be consistent with the expected trauma of life. There are normally no venous dilatations or varicosities.

Back 27

Abnormal Findings

Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse (see Table 12-6).

Front 28

Document the presence of any tattoos (a permanent skin design from indelible pigment) on the person's chart. Advise the person that the use of tattoo needles and tattoo parlor equipment of doubtful sterility increases the risk of hepatitis C.

Back 28

Abnormal Findings

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

Front 29

If any lesions are present, note the:

1. Color

2. Elevation: flat, raised, or pedunculated

3. Pattern or shape: the grouping or distinctness of each lesion, for example, annular, grouped, confluent, linear. The pattern may be characteristic of a certain disease.

4. Size, in centimeters: Use a ruler to measure. Avoid household descriptions such as “quarter size” or “pea size.”

5. Location and distribution on body: Is it generalized or localized to area of a specific irritant; around jewelry, watchband, around eyes?

6. Any exudate. Note its color and any odor.

Back 29

Abnormal Findings

Lesions are traumatic or pathological changes in previously normal structures. When a lesion develops on previously unaltered skin, it is primary. However, when a lesion changes over time or changes because of a factor such as scratching or infection, it is secondary. Study Table 12-3 for the shapes and Tables 12-4 and 12-5 for the characteristics of primary and secondary skin lesions. The terms used (macule, papule, etc.) are helpful to describe any lesion you encounter.

Front 30

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 if 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.

Back 30

Abnormal Findings

Note the pattern and characteristics of common skin lesions (see Table 12-9) and malignant skin lesions (Table 12-10), and lesions associated with AIDS (Table 12-11).

Front 31

Does the lesion blanch with pressure or stretch? Stretching the area of skin between your thumb and index finger decreases (blanches) the normal underlying red tones, thus providing more contrast and brightening the macules. Red macules from dilated blood vessels will blanch momentarily, whereas those from extravasated blood (petechiae) do not. Blanching also helps identify a macular rash in dark-skinned people.

Use a magnifier and light for closer inspection of the lesion (Fig. 12-7). Use a Wood's light (i.e., an ultraviolet light filtered through a special glass) to detect fluorescing lesions. With the room darkened, shine the Wood's light on the area.

Back 31

Abnormal Findings

Lesions with blue-green fluorescence indicate fungal infection, such as tinea capitis (scalp ringworm).

Front 32

otassium Hydroxide (KOH) Preparation.

Back 32

Microscopic examination of skin scrapings helps diagnose superficial fungal infections. Use a sharp sterile blade and lightly scrape the scale from the edge of a scaling lesion. Place on a clean slide. Add a drop of 10% to 20% potassium hydroxide (KOH) to dissolve nonfungal skin debris; send to the laboratory.

Front 33

Color

Hair color comes from melanin production and may vary from pale blonde to total black. Graying begins as early as the third decade of life because of reduced melanin production in the follicles. Genetic factors affect the age of onset of graying.

Texture

Scalp hair may be fine or thick and may look straight, curly, or kinky. It should look shiny, although this characteristic may be lost with the use of some beauty products such as dyes, rinses, or permanents.

Back 33

Abnormal Findings

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 (see Table 12-13).

Front 34

Distribution

Fine vellus hair coats the body, whereas coarser terminal hairs grow at the eyebrows, eyelashes, and scalp. During puberty, distribution conforms to normal male and female patterns. At first, coarse curly hairs develop in the pubic area, then in the axillae, and last in the facial area in boys. In the genital area the female pattern is an inverted triangle; the male pattern is an upright triangle with pubic hair extending up to the umbilicus. In Asians, body hair may be diminished.

Back 34

Abnormal Findings

Genital hair absent or with abnormal configuration suggests endocrine abnormalities.

Hirsutism—excess body hair. In females, this forms a male pattern of hair distribution on the face and chest and indicates endocrine abnormalities (see Table 12-13).

Front 35

Lesions

Separate the hair into sections and lift it, observing the scalp. With a history of itching, inspect the hair behind the ears and in the occipital area as well. All areas should be clean and free of any lesions or pest inhabitants. Many people normally have seborrhea (dandruff), which is indicated by loose white flakes.

Back 35

Abnormal Findings

Head or pubic lice. Distinguish dandruff from nits (eggs) of lice, which are oval, adherent to hair shaft, and cause intense itching (see Table 12-13).

Front 36

INSPECT AND PALPATE THE NAILS

Shape and Contour

The 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.

Back 36

Abnormal Findings

Jagged nails, bitten to the quick, or traumatized nail folds from chronic nervous picking suggest nervous habits.

Chronically dirty nails suggest poor self-care or some occupations in which it is impossible to keep them clean.

Front 37

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).

Back 37

Abnormal Findings

Clubbing of nails occurs with congenital chronic cyanotic heart disease and with emphysema and chronic bronchitis.

In early clubbing, the angle straightens out to 180 degrees and the nail base feels spongy to palpation.

Front 38

Consistency

The surface is smooth and regular, not brittle or splitting.

Back 38

Abnormal Findings

Pits, transverse grooves, or lines may indicate a nutrient deficiency or may accompany acute illness in which nail growth is disturbed (see Table 12-14).

Front 39

Nail thickness is uniform.

Back 39

Abnormal Findings

Nails are thickened and ridged with arterial insufficiency.

Front 40

The nail is firmly adherent to the nail bed, and the nail base is firm to palpation.

Back 40

Abnormal Findings

A spongy nail base accompanies clubbing.

Front 41

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.

Back 41

Abnormal Findings

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 (see Table 12-14).

Front 42

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.

Back 42

Abnormal Findings

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

Front 43

PROMOTING HEALTH AND SELF-CARE

Teach Skin Self-Examination

Back 43

Teach all adults to examine their skin once a month, using the ABCDE rule (see p. 231) 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 relative to search skin areas difficult to see (e.g., behind ears, back of neck, back). Follow the sequence outlined in Figure 12-11 and report any suspicious lesions promptly to a physician or nurse.
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Front 44

Adolescents

Back 44

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 if it is the milder form of open comedones (blackheads) (Fig. 12-19, A) and closed comedones (whiteheads). Severe acne includes papules, pustules, and nodules (Fig. 12-19, B). 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.

Front 45

The Pregnant Female

Back 45

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 (see Fig. 29-3). 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.

Front 46

Senile Lentigines.

Back 46

Commonly called liver spots, these are small, flat, brown macules (Fig. 12-20). 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.

Front 47

Aging Adult
Keratoses

Back 47

These lesions are raised, thickened areas of pigmentation that look crusted, scaly, and warty. One type, seborrheic keratosis, looks dark, greasy, and “stuck on” (Fig. 12-21). 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.

Front 48

Aging Adult
Keratoses

Back 48

Another type, actinic (senile or solar) keratosis, is less common (Fig. 12-22). 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.

Front 49

Aging Adult
Moisture.

Back 49

Dry skin (xerosis) is common in the aging person because of a decline in the size, number, and output of the sweat glands and sebaceous glands. The skin itches and looks flaky and loose.

Front 50

Aging Adult
Texture

Back 50

Common variations occurring in the aging adult are acrochordons, or “skin tags,” which are overgrowths of normal skin that form a stalk and are polyplike (Fig. 12-23). They occur frequently on eyelids, cheeks and neck, and axillae and trunk.

Front 51

Aging Adult
Sebaceous hyperplasia

Back 51

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 (Fig. 12-24).

Front 52

Aging Adult
Thickness.

Back 52

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.

Front 53

Aging Adult
Mobility and Turgor

Back 53

The turgor is decreased (less elasticity), and the skin recedes slowly or “tents” and stands by itself (Fig. 12-25).

Front 54

Aging Adult
Hair

Back 54

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.

Front 55

Aging Adult
Nails

Back 55

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.

Front 56

Aging Adult
Nails

Back 56

Abnormal Findings

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