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168 Cards in this Set
- Front
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2. Anatomy and Physiology: Skin Layers
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Epidermis
Dermis Appendages |
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Anatomy and Physiology: Skin Layers: Epidermis: layers
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stratum corneum, and the cellular stratum
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Anatomy and Physiology: Skin Layers: Epidermis: stratum corneum
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a. protects the body against environmental substances and restricts water loss.
b. Consists of closely packed dead squamous cells that contain keratin which is waterproofing. |
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Anatomy and Physiology: Skin Layers: Epidermis: cellular stratum
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a. keratin cells are synthesized in the stratum germanitivum (deepest sublayer of the cellular stratum).
b. Melanin is also produced in the stratum germanitivum, provides the pigment of the skin. |
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Anatomy and Physiology: Skin Layers: Dermis
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i. Vascular connective tissue.
ii. Separates the epidermis from the cutaneous adipose tissue iii. Upward projecting papulae penetrate the epidermis and supply nutrition to the living epidermal cells. iv. The last standing, collagen, and reticular fibers provide resilience, strength, and stability v. Sensory nerves are also in the dermis the provide pain, touch and temperature sensations. vi. Also contains autonomic motor fibers that innervate blood vessels, glands, and muscles that cause pyloerection |
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Anatomy and Physiology: Skin Layers: Hypodermis
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i. the dermis is connected to underlying organs by the hypodermis, a subcutaneous layer that consists of loose connective tissue filled with fatty cells
ii. this adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories |
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Anatomy and Physiology: Skin Layers: Appendages: Types
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Epidermis invaginates into the dermis at myriad points and forms the following appendages:
eccrine sweat glands, apocrine sweat glands, sebaceous glands, hair nails |
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Anatomy and Physiology: Skin Layers: Appendages: eccrine sweat glands
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a. open directly onto the surface of the skin and regulates body temperature through water secretion.
b. The glans are distributed throughout the body except at the lip margins, eardrums, nail beds, inner surface of the prepuce, glans penis |
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Anatomy and Physiology: Skin Layers: Appendages: apocrine sweat glands
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a. only in the axillae, nipples, areolae, anogenital, eyelids and external ears.
b. Larger glands and located more deeply than the eccrine glands c. Respond to emotional stimuli, secrete a white fluid (containing protein, carbohydrate, and other substances) which is odorless. d. Body odor is produced by bacterial decomposition of apocrine sweat |
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Anatomy and Physiology: Skin Layers: Appendages: sebaceous glands
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a. secrete sebum, a lipid rich substance that keeps skin and hair from drying out.
b. Stimulated by sex hormones mainly testosterone, it varies depending on maturation level. |
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Anatomy and Physiology: Skin Layers: Appendages: hair
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a. formed by epidermal cells that invaginates into the dermal layer
b. consists of a root, a shaft, and a follicle c. the papilla, a loop of capillaries at the base of the follicle, provide nourishment for growth d. adults have two kinds of hair: vellus and terminal i. vellus 1. short, fine, soft, and non-pigmented ii. terminal 1. coarser, longer, thicker, and usually pigmented |
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Anatomy and Physiology: Skin Layers: Appendages: nails
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a. epidermal cells converted to hard plates of keratin.
b. The highly vascular nail bed lies beneath the plate, giving the nail its pink color c. the white crescent shaped area extending beyond the proximal nail fold marks the end of the nail matrix, the site of nail growth d. cuticle or eponychium-the stratum corneum layer of skin covering the nail roots-pushes up and over the lower part of the nail body |
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3. Anatomy and Physiology: Skin Functions
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a. Protect from microbe invasion/minor trauma
b. Retard body fluid loss-most significant way to lose water is through burn c. Regulate temperature d. Sensory perception e. Produce Vitamin D i. Vitamin D: promote proper use of calcium and phosphorus, contribute to tooth and bone formation. f. Contribute to B/P regulation i. Blood pressure regulation by causing vasoconstriction or dilitation. g. Repair surface wounds h. Excrete urea, sweat, lactic acid i. Express emotions |
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Why is the skins function of producing vitamin D important?
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Vitamin D: promote proper use of calcium and phosphorus, contribute to tooth and bone formation.
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What is the most significant way to lose blood fluid through the skin?
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burns
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Anatomy and Physiology: Infants
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a. Skin smoother, less oily than adults
b. Desquamation of stratum corneum i. Desquamation of the straum corneum might occur at birth or shortly after. From mild flaking to shedding of large sheets of epidermis. c. Vernix caseosa i. a mixture of sebum and cornified epidermis, covers the infant's body at birth d. Subcutaneous fat poorly developed i. predisposes infants to hypothermia ii. difficult for newborns to thermal regulate-can't shiver-don't want newborns to shiver this will increase their temperature when they have a fever e. Lanugo i. fine, silky hair that covers the newborn's body, particularly the shoulders and back f. Eccrine glands function after 1 month g. Apocrine glands do not function i. this results in less oily skin and inoffensive perspiration |
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Anatomy and Physiology: Adolescents
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a. Apocrine glands activated
i. during adolescence, the apocrine glands enlarge and become active, causing increased axillary sweating and sometimes body odor ii. Apocrine glands: start to smell need to be counseled about this. b. Increased sebum production i. Sebum production in response to hormones (primarily androgen) leads to acne. ii. Speak about that can prevent scarring and emotional distress. c. Grow pubic/axillary hair (terminal hair)-response to changing androgen levels d. Facial hair in boys-response to changing androgen levels |
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Anatomy and Physiology: Pregnant Women
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a. Increased blood flow to skin leads to peripheral vasodilation an increased number of capillaries-especially in the hands and feet
i. help to dissipate the heat from the increased metabolic activity from pregnancy. b. Increased sweat/sebaceous gland activity i. acceleration of sweat and sebaceous gland activity occurs ii. help to dissipate the heat from the increased metabolic activity from pregnancy. c. Fat deposits d. Stretch marks e. Vascular spiders f. Increased pigmentation i. Increased pigmentation occurs in about 90% of pregnancies. ii. Seen in face, nipples, Areola, axillae, vulva, perianal skin, and umbilicus |
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Anatomy and Physiology: Older Adults
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a) Decrease Oil/sweat glands
b) Thin, flat epidermis i. taking on the look of parchment as a vascularity of the dermis decreases c) Decrease Elasticity of dermis a. loses collagen and elastic fibers, and shrinks, causing the epidermis to Fulton assume or wrinkled appearance d) Decrease Subcutaneous tissue i. subcutaneous tissue decreases particularly in the extremities, giving joints and bony prominences a sharp, angular appearance e) Decrease Melanocyte function i. Decreased melanocyte function causes gray hair. f) Decrease Axillary/pubic hair i. decrease in axillary and pubic hair as a result of reduced hormonal functioning g) Decrease Body/ head hair i. the density and rate of scalp hair growth declines with age ii. the size of hair follicles also change, and terminal scalp hair progressively transitions into vellus hair, causing age associated baldness and both man and women h) Increased Nasal/ear hair in men i) Increase Facial hair in women i. Increased facial hair in women because of increase androgen/estrogen ratio j) Decreased Nail growth i. because of decreased peripheral circulation ii. thin nails, particularly the toenails, become thicker, brittle, hard, and yellowish |
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1. History of Present Illness
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a. New or unusual contacts
i. Place 1. where it initially started ii. Chemicals 1. Medications, soaps, detergents, fabric softeners, makeup, lotions, pool/spa, new clothing, hotels iii. Food b. Pet Exposure i. Pet exposure: May be at a friends house, even if keep the dog in separate room the dander is still present in the house. ii. Cats especially-worst the under c. When and Wear Rash Started i. When and wear rash started: When first noted days, months, hours ago. Wear on the body it first started. d. Timing i. Timing: worse in am/pm, after work, after certain activities. |
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9. Skin Cancer Risk Factors
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a. Age: greater then 50
b. Fair and freckled c. Light colored hair or eyes d. Tendency to sunburn e. Blistering sunburns as a child f. Over exposure to the elements g. Near equator or high altitudes h. Exposure to arsenic, creosote, coal tar or petroleum products i. Family hx of skin Ca j. Overexposure to radiation k. Repeated trauma/irritation to the skin l. Precancerous lesions |
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10. Related History: Family History
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a. Dermatologic diseases
i. current or past dermatologic diseases or disorders and family members; melanoma; psoriasis for my: allergic skin disorders; infestation; bacterial, fungal, or viral infections b. Allergic hereditary diseases i. such as asthma or hay fever ii. people who have allergies (rashes) typically have severe asthma and vice versa c. Familial hair loss or coloration patterns d. Melanoma risk factor: Previous hx: 10x risk, Family hx: 8x risk, Immune suppression: 4x risk and blistering sunburn before 20 2x risk factor. |
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11. Related History: Older Adults
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a. Sensation changes
i. increased or decreased sensation to touch or the environment b. Generalized chronic itching i. exposure to skin irritants, detergents, lotions with high alcohol content, woolen clothing, humidity of environment c. Susceptibility to skin infections d. Delayed healing response i. delayed or interrupted e. Falls i. resulting in multiple cuts or bruises f. History of DM or PVD g. Hair loss history i. gradual versus sudden onset, loss pattern (symmetric or asymmetric) |
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12. Exam & Findings: Skin
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a. adequate lighting is essential.
b. Daylight provides the best illumination for determining color variations, particularly jaundice c. if daylight is unavailable or insufficient, supplemented with overhead fluorescent lighting d. inadequate lighting can result in inadequate assessment e. tangential lighting is helpful in assessing contour f. look for i. Color and uniform appearance 1. inspect the skin and mucous membranes (especially oral) for color and uniform appearance ii. Thickness 1. varies over the body 2. thinnest skin on the eyelids 3. thickest skin at areas of pressure arriving, most notably the soles, palms, and elbows 4. corns-flat or slightly elevated, circumscribed, painful lesions with a smooth, hard surface a. soft corns-caused by the pressure of the bony prominence against softer tissue; these appear as whitish beginnings, commonly between the fourth and fifth toes b. hard corns-sharply delineated and have a conical appearance; they occur most often over bony prominences were pressure is exerted, such as from shoes pressing on the inter-phalangeal joints of the toes 5. Callus a. a superficial area of hyper keratosis b. usually occurs on the weight-bearing areas of the feet and on the Palmar surface of the hands c. calluses are less well demarcated than corns and are usually not tender him or her iii. Symmetry iv. Hygiene v. Presence of lesions |
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Exam & Findings: Skin: NEVI
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a. occur in forms that vary in size and degree of pigmentation
b. nevi are present on most persons regardless of skin color, and may occur anywhere on the body c. they may be flat, raised slightly, dome shaped, smooth, rough, or hairy d. there are color ranges from pink, tan, gray, and shades of brown to black e. although most nevi are harmless, some may be dysplastic, precancerous, or cancerous f. dysplastic nevi tend to occur on the upper back in men in the legs woman |
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Exam & Findings: Skin: NEVI: Pigmented types: Halo Nevus
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i. Features
1. sharp, oval, or circular; depigmented Halo around mole; may undergo many morphologic changes; usually disappears and a little re-pigments (may take years) ii. occurrence 1. usually occurs on back in young adult iii. comments 1. usually benign; biopsy indicated because same process can occur around melanoma |
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Exam & Findings: Skin: NEVI: Pigmented types: Intradermal Nevus
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i. features
1. dome shaped; raised; flesh to black color; may be pedunculated or hair bearing ii. occurrence 1. cells limited to dermis iii. comments 1. no indication for removal other than cosmetic |
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Exam & Findings: Skin: NEVI: Pigmented types: Junctional Nevus
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i. features
1. flat or slightly elevated; dark Brown ii. occurrence 1. nevus cells lining dermoepidermal junction iii. comments 1. should be removed if exposed to repeated trauma |
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Exam & Findings: Skin: NEVI: Pigmented types: Compound Nevus
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i. features
1. slightly elevated brownish papule: indistinct border ii. occurrence 1. nevus cells in dermis and lining dermoepidermal junction iii. comments 1. should be removed if exposed to repeated trauma |
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Exam & Findings: Skin: NEVI: Pigmented types: Hairy Nevus
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i. features
1. may be present at birth; may cover large areas; hair growth may occur after several years ii. comments 1. should be removed if changes occur |
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Exam & Findings: Skin: NEVI: normal
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a. color
i. uniformly tan or brown; all moles on one person tend to look like b. shape i. round or oval with a clearly defined border that separates the mole from the surrounding skin surface ii. begins as flat, smooth spot on skin; becomes raised; forms a smooth bump c. size i. usually less than 6 mm (size of a pencil eraser) d. number i. typical adult has 10 to 40 moles scattered around the body e. location i. usually above the waist on sun exposed services the body; scalp, breast, and buttocks rarely have normal moles |
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Exam & Findings: Skin: NEVI: dysplastic
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a. color
i. mixture of tan, brown, black, and red/pink; moles on one person often do not look alike b. shape i. irregular borders may include notches; may fade into surrounding skin and include a flat portion level with skin c. surface i. may be smooth, slightly scaly, or have a rough, a regular, "pebbly" appearance d. size i. often larger than 6 mm and sometimes larger than 10 mm e. number i. many persons do not have an increased number; however, persons severely affected may have more than 100 moles f. location i. may occur anywhere in the body, but most commonly on back; may also appear below the waist and on scalp, breast, and buttock |
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Exam & Findings: Skin:cutaneous color changes
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i. Cutaneous Changes: cyanosis, jaundice, pale, etc.
ii. several variations in skin color occurring almost all healthy adults and children, including nonpigmented striae (i.e., silver pink "stretch marks" that occur during pregnancy or weight gain), freckles and sun exposed areas, some birthmarks, and some nevi iii. adult women will have chloasma, a areas of hyperpigmentation on the face and neck that are associated with pregnancy or use of hormones iv. pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic diseases such as diabetes mellitus and cardiovascular disease v. reddish purple discolorations may be related to localized hemorrhage into cutaneous tissues caused by injury, steroids, vasculitis, and several systemic disorders vi. ecchymosis discolorations produced by injury vii. petechiae-smaller than 0.5 cm in diameter viii. Purpura-larger than .5 cm in diameter |
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Exam & Findings: Skin: MOISTURE
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i. minimal perspiration or oiliness should be present
ii. increased frustration may be associated with activity, warm environment, obesity, anxiety, or excitement; it may be especially noticeable on the palms, scalp, four head, and in the axilla |
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Exam & Findings: Skin: TEMPERATURE
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i. the skin should racial cool to warm to touch
ii. use the dorsal surface of your hands or fingers because these areas are most sensitive to temperature perception iii. at best, this assessment is a rough estimate of temperature; what you are really looking for is bilateral symmetry |
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Exam & Findings: Skin: TEXTURE
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i. texture should feel smooth, soft, and even
ii. roughness unexposed areas are areas of pressure (particularly the elbows, souls, and palms) may be caused by heavy or woolen clothing, cold weather, or soap iii. extensive or widespread roughness may be the result of a keratinization disorder or healing lesions iv. hyper keratosis, especially on the palms and soles, may be a sign of a systemic disorder such as arsenic or other toxic exposure |
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Exam & Findings: Skin: TURGOR
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i. to assess turgor and mobility, gently pinch a small section of skin on the forearm or sternal area between the thumb and forefinger and then released the skin
ii. turgor should not be tested on the back of the patient's hand because of the looseness and thinness of the skin in that area iii. the skin should feel resilient, move easily when finished, and return to place immediately when released iv. turgor will be altered if the patient is substantially dehydrated or if edema is present |
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15. Exam & Findings: Skin Lesions: CHARACTERISTICS
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i. table eights – four and eight – five (page 166, 170)
ii. as you assess the skin, pay particular attention to any lesions that may be present iii. skin lesions-catchall term that collectively describes any pathologic skin condition or occurrence iv. lesions may be primary or secondary 1. primary a. those that occur as initial spontaneous manifestations of a pathologic process 2. secondary a. those that results from later evolution of or external trauma to a primary lesion 3. Vascular a. lesions associated with vascular issues. |
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Exam & Findings: Skin Lesions: CHARACTERISTICS: Types: Primary
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a. those that occur as initial spontaneous manifestations of a pathologic process
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Exam & Findings: Skin Lesions: CHARACTERISTICS: Types: Secondary
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a. those that results from later evolution of or external trauma to a primary lesion
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Exam & Findings: Skin Lesions: CHARACTERISTICS:Types: Vascular
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lesions associated with vascular issues
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define: Skin lesion
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catchall term that collectively describes any pathologic skin condition or occurrence
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describe lesions according to characteristics:
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1. Size, shape, color, texture
2. Elevation/depression 3. Pedunculation 4. Exudate a. color b. odor c. amount d. consistency 5. Location/distribution a. generalized or localized b. regions of the body c. patterns d. discrete or confluent |
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lesion measurement
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1. subjective estimate should not be used as measures of size; instead, use a ruler airport sizes in centimeters (inches may be used, but centimeters is the preferred unit of measure)
2. try to measure size and all dimensions (i.e., height, width, and depth) when possible |
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lesion: transillumination
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a. Transillumination may be used to determine the presence of fluid and cysts and masses
b. fluid filled lesions will transilluminate with a red glow, whereas solid lesions will not |
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lesion: woods lamp
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a. can be used to evaluate epidermal hyper pigmented or hyper pigmented lesions and to distinguish fluorescing lesions
b. darken the room and shine the light on the area to be examined c. look for the characteristic well demarcated hypo pigmentation of vitilago, hyperpigmentation of café au lait spots, and the yellow-green fluorescence that indicates the presence of some type of fungal infection d. Woods lamp: illumination with floures yellow/green to indicate presence of fungal infection. |
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3. Primary Skin Lesion: Macule
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a. description
b. Flat, circumscribed area with change in color, less then 1cm. c. Examples i. freckles, flat moles (nevi), petechiae, measles, scarlet fever |
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4. Primary Skin Lesion: Papule
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a. description
b. Elevated, firm, circumscribed lesion, less then 1 cm c. examples d. Lichen planus: Unknown cause, wart (verruca), elevated moles |
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5. Primary Skin Lesion: Patch
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a. description
b. Flat, nonpalpable, irregular shaped macule greater then 1cm c. example d. Vitiligo: loss of epidermal melanocytes, many times from an autoimmune process, also consider tinea corporis e. port wine stains, Mongolian spots, café au lait patch |
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6. Primary Skin Lesion: Plaque
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a. description
b. Elevated, firm, rough lesion with flat top greater then 1cm c. example d. Psoriasis: inherited condition e. Seborrheic f. Actinic keratoses |
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7. Primary Skin Lesion: Wheal
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a. description
i. Elevated, irregular shaped area of cutaneous edema, solid ii. transient, variable diameter b. examples i. insect bites, urticaria, allergic reaction |
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8. Primary Skin Lesion: Nodule
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a. Description
i. Elevated, firm circumscribed lesion, deeper in the dermis then a papule 1-2cm. b. Examples i. erythema nodosum, lipoma |
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9. Primary Skin Lesion: Tumor
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a. Description
i. Elevated and solid lesion, in dermis, greater then 2cm may or may not be clearly demarcated ii. b. Examples i. Lipoma: benign fatty growth ii. neoplasms, benign tumor, lipoma |
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10. Primary Skin Lesion: Vesicle
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a. description
i. Elevated, circumscribed superificial, not in dermis. Filled with serous fluid, less then 1cm b. Examples i. Varicella(chicken pox), herpes zoster (shingles) |
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11. Primary Skin Lesion: Bulla
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a. Description
i. Vesicle greater then 1cm in diameter b. Examples i. blister, pemphigus vulgaris |
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12. Primary Skin Lesion: Pustule
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a. Description
i. Elevated, superficial lesion similar to vesicle but filled with purulent fluid b. Examples i. impetigo, acne |
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13. Primary Skin Lesion: Cyst
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a. Description
i. Elevated, circumscribed encapsulated lesion in dermis or sub q ii. filled with liquid or semi solid material b. examples i. sebaceous cyst, cystic acne |
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14. Primary Skin Lesion: Telangiectasis
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a. Description
i. Fine, irregular, red lines produced by capillary dilation b. Examples i. Telangiectasia in rosacea |
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1. Secondary Skin Lesion: Scale
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a. Description
i. Heaped up, keratinized cells ii. Flaky skin, irregular, thick or thin, dry or oily iii. variation in size b. examples i. Dandruff: consider tinea capitus ii. Flaking of skin with seborrheic dermatitis following scarlet fever or flaking of skin following a drug reaction; dry skin |
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2. Secondary Skin Lesion : Lichenification
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a. Description
i. Rough, thickened epidermis. Usually related to persistent itching, rubbing and skin irritation. ii. often involves flexor surface of the extremity b. examples i. chronic dermatitis |
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3. Secondary Skin Lesion: Scar
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a. Description
i. Thin to thick fibrous tissue replaces normal skin following injury to dermis. b. Examples i. healed would or surgical incision |
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4. Secondary Skin Lesion: Keloid
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a. Description
i. Irregular elevated, progressive enlarging scar. ii. Grows beyond the boundaries of the wound. iii. Caused by excessive collagen formation during the inflammatory stage of healing. b. Examples i. keloid formation following surgery |
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5. Secondary Skin Lesion: Excoriation
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a. Description
i. Loss of epidermis, hollowed out crusted area, usually linear b. Examples i. abrasion or scratch, scabies |
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6. Secondary Skin Lesion: Fissure
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a. Description
i. Linear crack or break from the epidermis to the dermis, moist or dry. b. Example i. Athletes foot: tinea pedis ii. cracks at the corner of the mouth |
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7. Secondary Skin Lesion: Erosion
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a. Description
i. Loss of part of the epidermis, follows ruptures of blisters or vesicles ii. depressed, moist, glistening b. example i. varicella, variola after rupture |
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8. Secondary Skin Lesion: Ulcer
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a. Description
i. Loss of epidermis and dermis, concave ii. varies in size b. Examples i. Statsis ulcer: poor circulation ii. decubitus |
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9. Secondary Skin Lesion: Crust
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a. Description
i. Dried serum, blood or purulent exudate. Elevated ii. slightly elevated; size varies; Brown, red, black, tan, or straw-colored b. examples i. scab on abrasion, eczema |
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10. Secondary Skin Lesion: Atrophy
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a. Description
i. Thinning skin surface, loss of skin markings, paperlike, translucent b. example i. striae ii. aged skin |
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1. Vascular Skin Lesion: Petechia
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a. Red-purple nonblanchable discolorations less then 0.5cm
b. Intravascular defects, infection |
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2. Vascular Skin Lesion: Pupura
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a. Red-purple nonblanchable discoloration greater then 0.5cm
b. Intravascular defects, infection. |
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3. Vascular Skin Lesion: Hemangioma
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a. Red, irregular elevated well circumscribed lesion
b. Dilated dermal capillaries. |
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Hair: Inspection: Color
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1. color will vary from very light blonde to black to gray and may show alterations with rinses, dies, or permanents
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Hair: Inspection: distribution
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1. Fine vellus hairs cover the body, whereas coarse terminal hairs occur on the scalp, pubic and axillary areas, on the arms and legs (to some extent), and in the beards of men
2. the mail pubic care configuration is and upright triangle with hair extending midline to the umbilicus 3. the female pubic configuration is a inverted triangle; they hair makes dead been lying to the umbilicus 4. hirsutism-growth of terminal hair and a mail distribution pattern on the face, body, and pubic area. By itself or associated with other signs of viralization, may be a sign of an endocrine disorder |
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Hair: Inspection: quantity
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1. hair is commonly present on the scalp, lower face, neck, nares, ears, chest, axilla, back and shoulders, arms, legs, toes, pubic area, and are on the nipples
2. note hair loss, which can be either generalized or localized 3. inspect the feet and toes for hair loss that may indicate poor circulation or nutritional deficit 4. genetically predisposed men often display a gradual symmetric hair loss on the scalp during adulthood as a response to androgens 5. asymmetric hair loss may indicate a pathologic condition |
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Hair: Palpation: Texture
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1. the scalp hair may be coarse or fine, curly or straight, and should be shiny, smooth, and resilient
2. palpate scalp hair for dryness and brittleness that could indicate a systemic disorder |
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Nails: Inspection
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inspect the nails for color, weighing, configuration, symmetry, and cleanliness
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Nails: Inspection : color
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1. nail bed color should be variations of pink
2. there are physical clues in the nails that may indicate pathophysiologic problems 3. pigment deposits Urbanski be present in the nail bed of persons with dark skin 4. yellow discolorations occur with several nail disease, including psoriasis and fungal infections, and may also occur with chronic respiratory disease 5. proximal subungal fungal infection is associated with human immunodeficiency virus infection 6. diffuse darkening of the nails may arise from antimalarial drug therapy, candidal infection, hyperbilirubinemia, and chronic trauma, such as occurring with tightfitting shoes 7. green black discoloration, which is associated with Pseudomonas infection, may be confused with similar discoloration caused by injury to nail bed (subungal hematoma) 8. a single blue or black nail may indicate melanoma or bruising/bleeding from trauma 9. generalized blue nails may be caused by conditions that produce cyanosis such as asthma, cardiac disorders, and severe anemia 10. splinter hemorrhages, longitudinal red or brown streaks, may occur with endocarditis, vasculitis, and with severe psoriasis of the nail matrix or as a result of minor injury to the proximal nail bed (habit-tic deformity) 11. white spots in the nail bed, a common finding, result from Google manipulation or other forms of mild trauma 12. white streaks are transverse white pants are indicative of a systemic disorder 13. separation of the nail plate from the nail bed produces a white, yellow, or green tinge on it then the tiered portion of the nail bed |
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Nails: palpation
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i. to nail plates should feel hard and smooth with the uniform thickness
ii. thickening of the nail may occur with tightfitting shoes, chronic trauma, and some fungal infections iii. thinning of the nail plate may also be some nail diseases iv. pain in the area of the nail group may be secondary to ischemia v. gently squeeze the nail between your thumb and the pad of your finger to test for adherents of the nail to the nail bed. Separation of the nail plate from the bad is common with psoriasis, trauma, candidal, or Pseudomonas infection, and some medications vi. the nail bed should feel firm. A boggy nail that accompanies clubbing |
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Infants: expected color variations: acrocyanosis
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a. cyanosis of the hands and feet
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Infants: expected color variations: cutis marmorata
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a. transient modeling when infant is exposed to decrease temperature
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Infants: expected color variations: erythema toxicum
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a. pink papular rash with vesicles superimposed on thorax, back, buttocks, and abdomen; may appear in 24 to 48 hours and resolve after several days
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Infants: expected color variations: Mongolian spots
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a. irregular areas of deep blue pigmentation, usually in the sacral gluteal region; seen predominantly in newborns of African, Native American/American Indian, Asian, or Latin descent
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Infants: expected color variations:Salmon patches ("stork bites")
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a. flat, deep pink localized areas usually seen on the mid four head, eyelids, upper lip, and back of neck
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Infants: Jaundice/hyperbilirubinemia
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1. Defects: jaundice
2. physiologic jaundice may be present to a mild degree in as many as 50% or more of newborn infants 3. it usually starts after the first day of life in disappears by the 8 to 10 day but may persist for as long as 3 to 4 weeks 4. intense and persistent jaundice should suggest liver disease or severe overwhelming infection |
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Infants: Contour distortions
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1. inspects the skin for distortions and contour suggestive of hygromas, fluid containing masses, subcutaneous angioma, lyphangiomas, hemangiomas, nodules, and tumor
2. transillumination may help with there is a question about the density of the mass or amount of fluid 3. with more density and muscle it, there is less tendency to glow on transillumination |
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Infants: Skin Creases
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v. Skin creases indicating congenital abnormalities
1. examine the hands and feet of newborns for skin creases 2. flexion results increases that are readily discernible on the fingers, palms, and soles 3. one indicator of maturity is the number of creases; the older the baby, the more the creases there are 4. examine the crease pattern on the fingers and palms because certain abnormalities are associated with specific derangements of the pattern |
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Infants: Pinch skin for test of turgor
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i. the tissue turgor is best evaluated by gently pinching a fold of the abdominal skin between the index finger and thumb
ii. as with the adult, resiliency allows it to return to the undisturbed state when released iii. a child who is seriously dehydrated (i.e., more than 10% of body weight) or very poorly nourished will have skin that retains "tenting" after its pinched iv. how quickly detents disappears provides a clue to the degree of dehydration or malnutrition |
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Skin Assessment: Adolescent
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a. Exam same as for adult
b. Inspect for i. Increased oiliness/perspiration ii. Acne 1. Acne: Figure 7-76, pg 212 iii. Maturational changes 1. as a reflection of maturing apocrine gland function, increased axillary perspiration occurs, and the characteristic adult body odor develops during adolescence 2. hair on the extremities darkens and becomes coarser 3. pubic and axillary hair and both male and females develops and assumes adult characteristics 4. males develop facial and chest hair that varies in quantity and coarseness |
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Skin Assessment: Pregnant Women: Striae gravidarum
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1. Striae: Figure 7-27, pg 193
2. a.k.a. stretch marks 3. appear on the abdomen, thighs, and breasts during the second trimester pregnancy 4. they fade after delivery but never disappear |
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Skin Assessment: Pregnant Women: Telangectasias/hemangiomas
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1. there is a fivefold increase in telangiectasias (vascular spiders), which may be found on the face, neck, chest, arms; these appear during the second to fifth month of pregnancy and usually resolve after delivery
2. hemangiomas that were present before pregnancy may increase in size, or new ones may develop |
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Skin Assessment: Pregnant Women: Cutaneous tags
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1. either pedunculated or sessile skin tags that are most often found in the neck and upper chest
2. they result from either epithelial hyperplasia and are not inflammatory 3. most result spontaneously |
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Skin Assessment: Pregnant Women: Increased pigmentation
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1. an increase in pigmentation is common and is found to some extent in all pregnant women
2. the area is usually affected include the areolae and nipples, vulvar and perianal regions, axillae, and the linea Alba a. pigmentation of the linea Alba is called the linea nigra b. it extends from the symphysis pubis the top of the fundus in the midline 3. pre-existing pigmented moles (nevi) and freckles may darken, and some nevi increase in size 4. the chloasma or "mask of pregnancy" occurs frequently in pregnant women and is found in the four head, cheeks, bridge of the nose, and chin a. it is blotchy and apparent is usually symmetric |
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Skin Assessment: Pregnant Women: Palmar erythema
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1. common finding in pregnancy
2. diffuse redness covers the entire palmar surface 3. the cause is unknown, and it usually disappears after pregnancy |
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Skin Assessment: Pregnant Women: Itching
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1. itching over the abdomen impressed result of stretching is common and not a cause for concern; however, itching accompanied by rash may signal a pregnancy specific dermatosis, which requires further investigation
2. the itching is generalized but may be more severe on the palms and soles 3. be aware to the serious manifestations of underlying pathology |
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Skin Assessment: Pregnant Women: vii. Altered hair growth
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1. hair growth is altered in pregnancy by the circulating hormones
2. the growing phase of the Harris length and in hair loss is decreased 3. 2 to 4 months after delivery, increased hair shedding occurs 4. re-growth will occur in 6 to 12 months |
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Older Adults: INSPECT FOR: Skin changes
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1. may appear more transparent and paler and light-skinned individuals
2. pigment deposits, increased crackling, and hyper pigmented patches may develop, causing the skin to take a less uniform appearance 3. flaking or scaling, associated with drier skin that comes with aging, occurs most commonly over the extremities 4. the skin appears to hang loosely on the body frame as a result of general loss of elasticity, loss of underlying adipose tissue, and years of gravitational pull 5. you may observe tenting of the skin when testing for turgor. Thus in older adults, turgor may not be a reliable are valid estimate of hydration status |
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Older Adults: INSPECT FOR: Breakdown over bony prominences
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1. the immobility of some older adults, especially when combined with decreased peripheral vascular circulation, places them at risk for the development of decubitus ulcers (pressure sores)
2. during examination, pay particular attention to bony prominences and areas subject persistent pressure or shearing forces 3. heals and the sacrum are common sights in patients who are confined to bed 4. do not like to examine less obvious areas such as elbows, scapula, and back of the head |
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Older Adults: INSPECT FOR: Lesions
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1. several types of lesions may occur on the skin of healthy older adults. The following lesions are considered expected findings
a. Cherry angioma i. tiny, bright ruby red, brown papules that may become brown with time. The occur in virtually everyone older than 30 years and increased numerically with age b. seborrheic keratosis i. pigmented, praised, warty lesions, usually appearing on the face or trunk. These must be distinguished from actinic keratosis, which have malignant potential. Because the lesions may look similar, seek the assistance of an experienced practitioner for differential diagnosis c. sebaceous hyperplasia i. occurs as yellowish, flattened papules with central depressions d. cutaneous tags i. small, soft tags of skin, usually appearing on the neck and upper chest. They are attached the body by a narrow stalk (pedunculated) and may not be pigmented e. cutaneous horns i. small, hard projections of the epidermis, usually occurring on the forehead and face f. solar lentigines i. irregular, round, gray brown macules with a rough surface that occur in sun exposed areas. These are often referred to as "age spots" or incorrectly as "liver spots". They are epidermal proliferations that are early science of photo aging of skin |
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Older Adults: INSPECT FOR: Hair changes
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1. turns gray or white as melanocytes cease functioning
2. head, body, pubic, and axillary hair thins the becomes sparse and dryer 3. men may show an increase in course aural, nasal, and eyebrow hair; women tend to develop course facial hair 4. symmetric balding, usually frontal or submittal, often occurs in men |
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Older Adults: INSPECT FOR: Nail changes
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1. the nails thickened, become more brittle, and may be deformed, striated, distorted, or peeling. They may take on a yellowish color and may lose their transparency. These changes occur most often in toenails
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Skin - Nonmalignant abnormalities: CORN
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i. flat or slightly elevated, circumscribed, painful lesions with a smooth, hard surface
1. soft corns-caused by the pressure of the bony prominence against softer tissue; these appear as whitish beginnings, commonly between the fourth and fifth toes 2. hard corns-sharply delineated and have a conical appearance; they occur most often over bony prominences were pressure is exerted, such as from shoes pressing on the inter-phalangeal joints of the toes ii. INCREASED SKIN GROWTH |
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Skin - Nonmalignant abnormalities: CALLUS
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i. a superficial area of hyper keratosis
ii. usually occurs on the weight-bearing areas of the feet and on the Palmar surface of the hands iii. calluses are less well demarcated than corns and are usually not tender him or her iv. THICKENING FROM CONSTANT FRICTION |
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Skin - Nonmalignant abnormalities: ECZEMA DERMATITIS
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i. Definition
1. most common inflammatory skin disorder; several forms, including irritant contact dermatitis, allergic contact dermatitis, atopic dermatitis ii. Pathophysiology 1. common factor of the various forms is intracellular edema and epidermal breakdown 2. eczematous dermatitis has three stages: acute, subacute, and chronic 3. excoriation from scratching predisposes to infection causes crust formation iii. subjective data 1. itching may or may not be present 2. those with atopic dermatitis often report allergy history (allergic rhinitis, asthma) iv. objective data 1. acute phase characterized by erythematous, pruritic, weeping vesicles 2. subacute eczema characterized by erythema and scaling 3. chronic stage characterized by thick, lichenified, pruritic plaques 4. atopic dermatitis: during the childhood, lesions involve lectures, the nape, and the dorsal aspects of the limbs; and adolescence and adulthood, lichenified plaques affect the fractures, head, and neck v. AUTOIMMUNE |
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Skin - Nonmalignant abnormalities: FURUNCLE
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i. Definition
1. a.k.a. Boil 2. a deep-seated infection of the pilo sebaceous units ii. Pathophysiology 1. Staphylococcus aureus most common organism 2. initially, a small perifollicular abscess that spreads to the surrounding dermis and subcutaneous tissue 3. may occur singly or in multiples; when infection involve several adjacent follicles, a coalescent purulent mass or carbuncle occurs iii. subjective data 1. acute onset of tender bread nodule that becomes pustular iv. objective data 1. skin red, hot, tender 2. center of lesion fills with pus and forms a core that they rupture spontaneously or require surgical incision 3. sites commonly involved by the face and neck, the arms, axilla, breast, thighs, and buttocks v. ABSCESS |
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Skin - Nonmalignant abnormalities: FOLLICULITIS
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i. Definition
1. inflammation and infection of the hair follicle that surrounds the dermis 2. RELATED TO SHAVING ii. Pathophysiology 1. presence of inflammatory cells within the wall and ostia of the hair follicle creates a follicular base pustule 2. inflammation can either be superficial or deep; deep folliculitis can result from the chronic lesion of superficial folliculitis or from lesions that are manipulated 3. persistent reoccurrence lesions may result in scarring or permanent hair loss iii. subjective data 1. acute onset papules and pustules associated with pruritis or mild discomfort; may have pain with deep folliculitis 2. risk factors: frequency being, immunosuppression, pre-existing dermatosis, long-term antibiotic use, occlusive clothing and/or occlusive dressings, exposure to hot humid temperatures, diabetes mellitus, obesity, and use of EGRF inhibitor medications iv. objective data 1. primary lesion small pustule 1 to 2 cm in diameter that is located over the Pilo sebaceous orifice and may be perforated by hair 2. pustule may be surrounded by inflammation or nodule lesions; after the pustule ruptures, crust forms 3. may have suppurative drainage with deep folliculitis 4. any hair bearing site can be affected; the site's most often involved of the face, scalp, thighs, axilla, inguinal area |
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Skin - Nonmalignant abnormalities: CELLULITIS
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i. Definition
1. diffuse, acute, infection of the skin and subcutaneous tissue ii. Pathophysiology 1. majority of cases caused by Streptococcus pyrogenes 2. and Staphylococcus aureus iii. subjective data 1. break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound 2. pain and swelling at the site 3. may have fever iv. objective data 1. skin red, hot, tender, and indurated; borders are not well demarcated 2. lymphangitic streaks and regional lymphadenopathy may be present |
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Skin - Nonmalignant abnormalities: TINEA
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i. Definition
1. group of non-candidal fungal infections have involved the stratum corneum, nails, or hair ii. Pathophysiology 1. infection of the dermatophytes, typically acquired by direct contact with infected humans or animals; invade the skin and survive and dead keratin 2. lesions usually classified according to anatomic location and can occur on nondairy parts the body (tinea corporis), on the groin and inner thigh (tinea cruris), on the scalp (tinea capitis), on the feet (tinea pedis), and on the nails (tinea unguium) iii. subjective data 1. may report pruritis iv. objective data 1. lesions vary in appearance and may be papular, pustular, vesicular,erythematous, or scaling 2. secondary bacterial infection may be present 3. microscopic examination of skin scrapings with KOH solution shows presence of hyphae 4. infected nails are yellow and thick and may separate from the nail bed |
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Skin - Nonmalignant abnormalities: PITYRIASIS ROSEA
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i. Pityriasis rosea: unknown cause, typical christmas tree distribution occurs on the chest. Lesions in parellal alignment that follow the ribs.
ii. Definition 1. self-limiting inflammation of unknown cause iii. Pathophysiology 1. sudden onset with occurrence of a primary (Herald) oval around plaque 2. a ruptured occurs 1 to 3 weeks later and last for several weeks 3. not contagious or infectious iv. subjective data 1. pruritus may be present with the generalized or option 2. Harold lesion often missed v. objective data 1. lesions usually pale, erythematous, and macular with fine scaling, but may be papular vesicular 2. lesions develop on the extremities and trunk; palms and soles are not involved, and facial involvement is rare 3. trunk lesions characteristically distributed and parallel alignment following the direction of the ribs and a Christmas tree light pattern |
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Skin - Nonmalignant abnormalities: PSORIASIS
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i. Definition
1. chronic and recurrent disease of keratin synthesis ii. Pathophysiology 1. multifactorial origin with genetic component and immune regulation 2. characterized by increased epidermal cell turnover, increased numbers of epidermal stem cells, and abnormal differentiation of keratin expression leading to thickened skin with copious scale iii. subjective data 1. may have pruritus 2. concerns about appearance iv. objective data 1. characterized by well circumscribed, dry, silvery, scaling papules and plaques 2. lesions commonly occur on the back, buttocks, extensor surfaces of the extremities, and scalp |
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Skin - Nonmalignant abnormalities: ROSACEA
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i. Rosacea: Chronic inflammatory skin disorder, usually seen on the middle of the face. Treat with topical antibiotics.
ii. Definition 1. chronic inflammatory skin disorder iii. Pathophysiology 1. lasts over years, with episodes of activity followed by quiescent periods of variable length 2. cause unknown; occurs most often in persons with a fair complexion iv. subjective data 1. itching always absent 2. many patients report a stinging pain associated with flushing episodes 3. common triggers: exposure to the sun, cold weather, sudden emotion, including laughter or embarrassment, hot beverages, spicy foods, and alcohol consumption v. objective data 1. eruptions appear on the four head, cheeks, nose, and occasionally around the eyes 2. characterized by telegiectasia, erythema, papules, and pustules that occur particularly in the central area of the face 3. although rosacea resembles acne, comedones are never present 4. tissue hypertrophy of the nose may occur ( rhinophyma) 5. Rhinophyma is characterized by sebaceous hyperplasia, redness, prominent vascularity, and swelling of the skin of the nose |
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Skin - Nonmalignant abnormalities: DRUG ERUPTIONS
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i. Pathophysiology
1. immunologically mediated cutaneous reactions to medications include IGE-dependent, cytotoxic, I mean complex, and cell mediated hypersensitivity reactions 2. nonimmunologically mediated reactions include direct release of mast cells mediators and idiosyncratic reactions ii. subjective data 1. rash appears from one to several days after taking the drug 2. pruritus characteristic iii. objective data 1. most common: discrete or confluent erythematous macules and papules on the trunk, face, extremities, palms, or soles of the feet 2. rash fades in one to three weeks |
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Skin - Nonmalignant abnormalities: HERPES ZOSTER
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i. Zoster: is a activitated chicken pox virus.
ii. Definition 1. Varicella zoster viral (VZV) iii. Pathophysiology 1. VZV morphologically and antigenically identical to the virus causing varicella (chickenpox) 2. dormant viral particles (since the original episode of varicella) in the posterior spinal ganglia are cranial sensory ganglia become activated iv. subjective data 1. pain, itching, or burning of the dermatome area usually perceived irruption by 4 to 5 days v. objective data 1. single dermatome that consist of red, swollen plaques or vesicles and become filled with purulent fluid |
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Skin - Nonmalignant abnormalities: HERPES SIMPLEX
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i. Definition
1. infection by herpes simplex virus (HSV) ii. Pathophysiology 1. two different virus types caused the infection: type I, usually associated with oral infection, and type II, with genital infection 2. crossover infections are becoming common iii. subjective data 1. tenderness, pain, paresthesia, or mild burning at the infected site before onset of the lesions iv. objective data 1. groups vesicles appear on the erythematous base and then erode, forming a crust 2. lesions last 2 to 6 weeks |
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Skin - Malignant abnormalities: Basal cell carcinoma
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i. BasaL Cell: most common malignant neoplasm, commonly on the face. Fair haired people and sun exposure risk factors. Varies in presentation
ii. Definition 1. the most common form of skin cancer iii. pathophysiology 1. cancer arises in the basal layer of the epidermis 2. occurs in various clinical forms including nodular, pigmented, cystic, sclerosing, and superficial 3. occurs most frequently unexposed parts of the body-the face, ears, neck, scalp, shoulders iv. subjective data 1. persistent sore lesions that has not healed 2. may have crusting 3. may itch v. objective data 1. shiny nodule that is pearly are translucent; may be pink, red, or white, tan, black, or Brown 2. open sore; may have crusting; may bleed 3. reddish patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs 4. pink growth with a slightly elevated rolled border and a crusted indentation in the center; as the growth slowly enlarges, tiny blood vessels may develop on the surface 5. scar like area that is white, yellow or waxy, and often has poorly defined borders; the skin appears shiny and taut. |
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Skin - Malignant abnormalities: Squamous cell carcinoma
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i. Squamous Cell: Malignant tumor arises from the epithelium. Sun exposed areas most common. Soft, mobile, elevate with scaling surface.
ii. Definition 1. second most common skin cancer iii. pathophysiology 1. this malignant tumor arises in the epithelium 2. lesions occur most commonly in sun exposed areas, particularly the scalp, back of hands, lower lip, and ear; the rim of the ear and the lower lip are especially vulnerable iv. subjective data 1. persistent sore lesion that has not healed or that has grown in size 2. may have crusting and/or bleeding v. objective data 1. elevated growth with the central depression 2. wartlike growth; may have crusting, may bleed 3. scaly red patch with irregular borders may have crusting, may bleed 4. scaly red patch with irregular borders 5. open sore; may have crusting |
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Skin - Malignant abnormalities: Melanoma
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i. Melanoma: develops from melanocyte cells, migrate into the skin and other structures during fetal development. Cause is unknown, herediatry and sun exposure are risk factors. Suspect if any change in a nevus.
ii. Definition 1. lethal form of skin cancer that develops from melanocytes iii. pathophysiology 1. melanocytes migrate into the skin, I, central nervous system, and mucous membrane during fetal development 2. less than half of the melanomas develop from nevi; the majority arise de novo from melanocytes 3. the exact cause of malignancy is not known; heredity, hormonal factors, ultraviolet light exposure, or an auto immunologic effect may contribute to causation iv. subjective data 1. new more pre-existing mole that has changed or is changing 2. new pigmented lesion that has irregularities 3. history of melanoma 4. history of dysplastic or atypical nevi 5. family history of melanoma (first-degree relative) v. objective data 1. ABC's of melanoma a. A-asymmetry of lesion. One half of the molar birthmark does not match the other b. B-borders. Edges are a regular, ragged, notched, or blurred. Pigment may be streaming from the border c. C-color. The color is not the same all over and may have differing shades of Brown or black, sometimes with patches of red, white, blue d. D- diameter. The diameter is greater than 6 mm (about the size of a pencil eraser) or is growing larger e. E-evolution. Changes in existing pigmented lesions, particularly in a nonuniform, asymmetric manner |
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Skin - Malignant abnormalities: Kaposi sarcoma
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i. Kaposi sarcoma: Tumor of endothelium and epithelial layers of skin. Soft, vascular and painless. Common in HIV
ii. Macular or papular lesions. Cancer in the endothelium and epithelial layer. iii. Definition 1. a neoplasm of the endothelium and epithelial layer of the skin iv. pathophysiology 1. caused by the Koposi sarcoma herpes virus 8 (KSHV) 2. individuals infected with KSHV are more likely to develop KSHV if there immune system is compromised 3. commonly associated with human immunodeficiency virus infection (HIV) v. subjective data 1. characteristics skin lesions 2. may report peripheral lymphedema 3. may be presenting symptom of HIV/AIDS vi. objective data 1. cutaneous lesions are characteristically soft, vascular, bluish purple, and painless 2. lesions may be either macular papular and may appear as plaques, keloids, or ecchymotic areas 3. KS lesions may be limited to the skin or involve the mucosa, viscera, and lymph nodes or any organ |
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Hair - Abnormalities: Alopecia areata
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i. Alopecia areata: sudden rapid hair loss usually on the face or scalp. Total hair regrowth is excellent.
ii. Definition 1. sudden, rapid, patchy loss of hair, usually from the scalp or face iii. pathophysiology 1. cause unknown; a genetic-environmental interaction may trigger the disease 2. any hair-bearing surface may be affected 3. regrowth begins in 1 to 3 month; the prognosis for total regrowth is excellent in cases with limited involvement iv. subjective data 1. sudden, rapid, patchy hair loss 2. may also report nail painting 3. may have family history v. objective data 1. hair loss is a sharply defined around areas 2. the hair shaft is poorly formed and breaks off at the skin surface |
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Hair - Abnormalities: Scarring alopecia
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i. Pathophysiology
1. skin disorders of the scalp or follicles resulting in scarring and destruction of the hair follicles and permanent hair loss ii. subjective data 1. may have other concurrent skin or systemic disorders iii. objective data 1. patchy hair loss 2. scalp may be inflamed 3. hair follicles may be pustular or plugged |
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Hair - Abnormalities: Traction alopecia
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i. Pathophysiology
1. prolonged tension of the hair from traction breaks the hair shaft 2. follicle is not damaged and the loss is reversible ii. subjective data 1. history of wearing certain hairstyles such as Braves or from using hair rollers and hot combs iii. objective data 1. patchy hair loss that corresponds directly to the area of stress 2. scalp may or may not be inflamed |
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Hair - Abnormalities: Hirsutism
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i. Hirsutism: male pattern hair distribution in a female
ii. Definition 1. growth of terminal hair and women in the mail distribution pattern on the face, body, and pubic areas iii. pathophysiology 1. caused by high androgen levels (from ovaries her adrenal glands) or by hair follicles that are more sensitive to normal androgen levels; free testosterone is the androgen that causes hair growth 2. many causes, including genetic, physiologic, endocrine, drug-related, and systemic disorders iv. subjective data 1. excessive hair growth on the face or body 2. onset, severity, and rate dependent on underlying cause v. objective data 1. presence of thick, dark terminal hairs in androgen sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea Alba 2. hirsutism may or may not be a, need by other signs of virilization |
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Nails - Infection: Paronychia
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i. Definition
1. inflammation of the paronychium ii. pathophysiology 1. invasion of bacteria between the nail fold and the nail plate 2. can occur as an acute or chronic process iii. subjective data 1. acute: history of nail trauma or manipulation; acute onset 2. chronic: history of repeated exposure to moisture, e.g., through handwashing; evolve slowly initially with tenderness and mild swelling iv. objective data 1. redness, swelling, tenderness at the lateral and proximal nail folds 2. purulent drainage option accumulates under the cuticle 3. Chronic paronychia can produce rippling of the nails |
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Nails - Infection: Tinea unguium
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i. Tinea: fungus
ii. Definition 1. fungal infection of the nail iii. pathophysiology 1. the fungus grows in the nail plate, causing it to crumble iv. subjective data 1. characteristic nail changes 2. may report associated discomfort, parethesia, loss of manual dexterity; may interfere with the ability to exercise, or walk v. objective data 1. in the most common form, the distal nail turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed 2. pitting does not occur, distinguishing it from psoriasis |
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Nails - Injury: Ingrown
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i. Definition
1. nail pierces lateral nail fold and grows into the dermis ii. pathophysiology 1. caused by lateral pressure of poorly fitting shoes, improper or excessive trimming of lateral nail plate, or trauma iii. subjective data 1. pain and swelling 2. history related to cause: tight shoes, excessive trimming, trauma iv. objective data 1. redness and swelling at the area of nail penetration 2. commonly involves the large toe |
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Nails - Injury: Subungual hematoma
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i. Definition
1. trauma to the nail plate severe enough to cause immediate bleeding and pain ii. pathophysiology 1. amount of bleeding may be sufficient to cause separation and loss of the nail plate 2. trauma to the proximal nail fold may also cause bleeding that is not apparent for several days 3. hematoma remains until nail grows out or is decompressed to release the blood and relieve the pressure iii. subjective data 1. trauma to the nail iv. objective data 1. discolored dark nail |
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Nails - Injury: Leukonychia punctate
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i. Leukonychia punctata: white spots on the nail from minor trauma. Usually grow out.
ii. Definition 1. white spots in the nail plate iii. pathophysiology 1. occur as a result of minor injury or manipulation of the cuticle 2. injury at the cuticle damages the nail matrix (area of nail growth) 3. either resolve spontaneously or grow out iv. subjective data 1. minor trauma to or manipulation of the nail v. objective data 1. small white spots on the nail plate |
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Nails - Injury: Habit - tic deformity
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i. Habit-tic: constant picking at the nail.
ii. Definition 1. nail deformity as a result of nail picking are biting habit iii. pathophysiology 1. injury at the cuticle damages the nail matrix (area of nail growth) iv. subjective data 1. history of fighting are picking the proximal nail fold of the thumb with the index finger v. objective data 1. horizontal sharp grouping in a band that extends to the top of the nail |
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Nails - Injury: Onycholysis
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i. Onycholysis: seperation of the nail from the bed. From trauma or infection.
ii. Definition 1. loosening of the nail plate with separation from the nail bed that begins at the distal groove iii. pathophysiology 1. associated most commonly with minor trauma to long fingernails 2. other causes include psoriasis, Candida, or Pseudomonas infections, medications, allergic contact dermatitis, and hyperthyroidism iv. subjective data 1. painless separation of the plate from the bed 2. may report history of nail trauma v. objective data 1. nonadherent portion of the nail opaque with a white, yellow, or green tinge |
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Nails – Signs of Systemic Disease: Koilonychia
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i. Koilonychia: spoon nail Associated with iron deficency, syphillis, fungal, hypothyroidism
ii. Definition 1. central depression of the mail lateral elevation of the nail plate iii. pathophysiology 1. associated with iron deficiency anemia, syphilis, fungal dermatosis, and hypothyroidism iv. subjective data 1. history consistent with associated disorders v. objective data 1. concave curvature and spoon appearance |
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Nails – Signs of Systemic Disease: Beau lines
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i. Beau Lines: represent a periods of severe stress to the body that interupted nail formation.
ii. Definition 1. transverse depression of the nail but iii. pathophysiology 1. temporary interruption of nail formation, due to systemic disorders 2. associated with coronary occlusion, hypercalcemia, and skin disease iv. subjective data 1. history consistent with associated disorders v. objective data 1. transverse depressions at the bases of the lunulae when the nail grows out |
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Nails – Signs of Systemic Disease: White banding
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i. White Bands: Terry nails: White nails except for a thin band of normal nailbed. Associated with cirrhosis and hypoelbuminemia
ii. Definition 1. transverse white bands iii. pathophysiology 1. associated with cirrhosis, chronic congestive heart failure, adult onset diabetes mellitus, and age 2. speculated that occurs as part of aging and that associated disease (age) the nail iv. subjective data 1. history consistent with associated disorders v. objective data 1. transverse white bands cover the nail except for a narrow zone at the distal tip |
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Nails – Signs of Systemic Disease: Psoriasis
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i. Definition
1. chronic and reoccurrence disease of keratin synthesis ii. pathophysiology 1. nail involvement usually occur simultaneously with skin disease but may occur as an isolated finding iii. subjective data 1. psoriatic lesions on skin iv. objective data 1. pitting, onycholysis, discoloration, and subungual thickening 2. yellow scaly debris often accumulates, elevating the nail plate 3. severe psoriasis of the matrix and nailbed resulting grossly malformed nails and splitter hemorrhages |
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Nails - Periungual growths: Warts
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i. Definition
1. epidermal neoplasms caused by viral infection ii. Subjective Data 1. a growth at the nail fold iii. Objective Data 1. occur at the nail fold then extend under the nail 2. longitudinal nail groove in the nail may occur from warts located over the nail matrix |
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Nails - Periungual growths: Digital mucous cysts
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i. Digital Mucous Cyst: jel filled cyst to the epinychium can cause a grove in the nail.
ii. Definition 1. cyst like structure contains a clear jellylike substance iii. Pathophysiology 1. cyst on the proximal nail fold are not connected to the joint space or tendon sheath; they result from localized fibroblast proliferation; compression of the nail matrix cells induces a longitudinal nail groove 2. cysts located on the dorsal lateral finger at the distal interphalangeal joint (DIP) are probably caused by herniation the tendencies or joint linings that are related to ganglion and synovial cysts iv. Subjective Data 1. cyst on the proximal nail fold or dorsal lateral aspect of distal finger v. Objective Data 1. cysts containing clear substance 2. longitudinal nail groove may occur from cysts located at the proximal nail fold |
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Children: Café au lait patches
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i. Café au lait: irregularly shaped patches, could indicated underlying disease.
ii. Definition iii. Pathophysiology iv. Subjective Data v. Objective Data |
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Children: Miliaria
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i. Miliaria: prickly heat
ii. Pathophysiology 1. caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity 2. results from immaturity of skin structures 3. overdressed babies are susceptible to this condition in the summer iii. Subjective Data 1. parent reports rash noted when addressing the infant iv. Objective Data 1. a regular, red, macular rash, usually uncovered areas of the skin |
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Children: Impetigo
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i. Definition
1. comment, contagious superficial skin infection ii. Pathophysiology 1. caused by staphylococcal infection and/or infection of the epidermis iii. Subjective Data 1. lesion, typically on the face, that itches and burns iv. Objective Data 1. an initial lesion is a small erythematous vacuole that changes into a vesicle or bulla with a thin roof 2. lesion crusts with a characteristic honey color from the exudate as the vesicles or bullae rupture 3. may have regional lymphadenopathy |
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Children: Acne vulgaris
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i. Pathophysiology
1. androgens stimulate the Pilo sebaceous units at the time of puberty to enlarge and produce a large amount of sebum 2. simultaneously, the keratinization process in the Pilo sebaceous canal is disrupted with impaction in obstruction of the outflow sebum resulting in comedo formation-open black heads enclosed whiteheads 3. wall of the closed comedo may rupture, spilling the follicular contents into the dermis, leading to the development of inflammatory papules 4. the presence of P. Acnes brings in neutrophils, which causes the inflammatory response ii. Subjective Data 1. most commonly reported by adolescents 2. may occur initially as an adult or continuing to the adult years 3. patient reports comedones (plugged follicles-blackheads and whiteheads), papules, and pustules over the four head, nose, cheeks, lower face, chest, and back that of all of the face, chest, and back iii. Objective Data 1. noninflammatory acne: comedones 2. inflammatory acne: papules or nodules 3. characteristic (ice pick) scarring may be present form previous lesions |
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Children: Chickenpox (Varicella)
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i. Chickenpox: Start on scalp and trunk and move outwards. Vessicles. Several stages of maturation. Contagious until scab over.
ii. Definition 1. acute, highly communicable disease common in children and young adults iii. Pathophysiology 1. caused by VZV 2. VZV communicable by direct contact, droplet transmission, and airborne transmission 3. incubation period 2 to 3 weeks; the period of communicability last from one or two days before the onset of the rash until lesions have crusted over 4. preventable by immunization 5. after primary infection, VZV remains dormant and sensory nerve roots for life iv. Subjective Data 1. fever, headaches, sore throat, malaise 2. pruritic rash that started on scalp and then moved to extremities 3. started as macular papular and in a few hours becomes vesicular v. Objective Data 1. macular papular and vesicular lesions on trunk, extremities, face, buccal mucosa, palate, or conjunctiva 2. lesions usually occur in successive outbreaks, with several stages of maturity present at one time 3. complications include conjunctival involvement, secondary bacterial infection, viral pneumonia, encephalitis, aseptic meningitis, myelitis, Guillain-Barré syndrome, and Reye syndrome |
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Children: Measles (Rubeola)
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i. Measles: Start on face and neck and spread to trunk and extremities. Viral, prodome fever, conjuntvitis, bronchitis. Ends 4 days after the rash appears.
ii. Definition 1. also called hard measles or red measles iii. Pathophysiology 1. measles virus infects by invasion of the respiratory epithelium 2. local multiplication at the respiratory mucosa leads to the primary viremia, during which the virus beds of leukocytes to the reticuloendothelial system 3. both endothelial and epithelial cells are infected; infected tissues include thymus, spleen, lymph nodes, liver, skin, conjunctiva, and lung 4. incubation period is commonly 18 days; the period of communicability last from a few days before the fever to four days after appearance of the rash 5. disease preventable by immunization iv. Subjective Data 1. characteristic prodromal fever, conjunctivitis, coryza, and bronchitis occur, followed by red, blotchy rash first of the face and then spreading to trunk and extremities v. Objective Data 1. Koplik spots (discrete white macular lesions) on the buccal mucosa 2. macular rash develops the face and neck 3. maculopapular lesions on trunk and extremities and irregular confluent patches 4. rash last 4-7 days 5. symptoms may be mild or severe 6. complications involve infection of the respiratory tract of central nervous system |
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Children: German measles (Rubella)
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i. German measles: fine maculopapular eruption on the hariline that spreads rapidly cephlocaudally. Occipital or posterior cervical lymphadenopathy. During first trimester usually leads to birth defects.
ii. Definition 1. mild, febrile, highly communicable viral disease iii. Pathophysiology 1. spreading droplets that are shed from respiratory secretions of infected persons 2. patients are most contagious while the rash is erupting, but they may shed virus from the throat from 10 days before until 15 days after the onset of the rash 3. incubation period is 14 to 23 days 4. disease preventable by immunization iv. Subjective Data 1. prodromal period, low grade fever, coryza, sore throat, and cough 2. followed by macular rash on the face and trunk that rapidly becomes papular v. Objective Data 1. generalized light pink to red maculopapular rash 2. by the second day, rash spreads to the upper and lower extremities; it feeds within three days 3. reddish spots occur on the soft palate during the prodromal or on the first day of the rash 4. infection during the first trimester of pregnancy may lead to infection of the fetus and may produce a variety of congenital anomalies (congenital rubella syndrome) |
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Children: Physical abuse
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i. physical findings in children were physically abused include bruises, burns, lacerations, scars, bony deformities, alopecia, rental hemorrhages, dental trauma, and had and abdominal injuries.
ii. Bruises: there may be patterned consistent with the implement used, such as belt marks, marks from a looped electric cord, and oval or fingertip grab marks. Perusing associated with abuse occurs over soft tissue; toddlers and older children who bruise themselves accidentally do so over bony prominences. any bruise in an infant who is not yet developmentally able to be mobile should be a cause for concern iii. lacerations: laceration of the frenulum and lips are associated with force bleeding. Human bites can cause breaks in the skin and leave a characteristic bite mark iv. burns: patterns that are common include scald burns in stockings and glove distribution (when gloves and fear place on hot surfaces are immersed); but I burned consistent with immersion; and cigarette burns, a characteristic small, round burn, often on areas hidden by clothing. The absence of splash marks or pattern consistent with spills of hot liquid may be helpful in differentiating accidental from deliberate v. hair loss; patchy hair loss or bald spots, in the absence of the scalp disorders such as ringworm, may indicate repeated here pulling |
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Older Adult: Stasis dermatitis
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i. Stasis Dermatitis: from edema and related to peripheral vascular disease.
ii. Pathophysiology 1. occurs on the lower legs in some patients with venous insufficiency 2. incompetent venous valves, inadequate tissue support, and postural hydrostatic pressure contributed development of venous stasis 3. dermatologic changes secondary to the effects of extravasated blood, which induces a mild inflammatory response in the dermis and subcutaneous fat 4. most patients with venous insufficiency do not develop dermatitis, which suggests that genetic or environmental factors may play a role 5. may occur as an allergic response to an epidermal protein antigen created through increased hydrostatic pressure, or because the skin has been compromised and is more susceptible to irritation and trauma iii. Subjective Data 1. sense of fullness or dull aching in the lower legs and ankles 2. gradual increase in pigmentation and redness 3. area may be itchy and/or painful iv. Objective Data 1. Erythematous, scaling, weeping patches on lower extremity; ulceration may be present 2. dermatitis may be acute, subacute, or chronic and recurrent |
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Older Adult:Solar keratosis
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i. Solar Keatosis: secondary to chronic sun damage, has malignant potential.
ii. Definition 1. squamous cell carcinoma confined to the epidermis iii. Pathophysiology 1. occurs secondary to chronic sun damage 2. most lesions remain superficial; lesions that extend more deeply to involve the papillary and/or reticular dermis or termed squamous cell carcinoma iv. Subjective Data 1. history of chronic sun exposure 2. increasing number of lesions with age v. Objective Data 1. slightly raised erythematous lesion that is usually less than 1 cm in diameter with an irregular, rough surface 2. lesion is most common on the dorsal surface of the hands, arms, neck, and face |
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Older Adult: Physical abuse
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i. abuse in older adults can assume the form of physical abuse, neglect, sexual abuse, psychological abuse, financial abuse, or violation of rights
ii. physical neglect is probably the most common type of abuse encountered by healthcare professionals. However, be aware that when one form abuse is present, it is typically accompanied by other forms iii. physical abuse and neglect may present with clues that aid in detection iv. assessment of general periods may indicate poor hygiene, emaciation, healed fractures with deformity, unexplained trauma v. carefully inspect the skin, particularly on hidden areas such as the axilla, inner thighs, soles of the feet, palms, and abdomen; look for bruising, burns, abrasions, or areas of tenderness vi. bruising on extensor surfaces is common in usually occurs accidentally; bruising at various stages of resolution located on inner soft surfaces is more likely to indicate abuse vii. careful history taking is essential viii. when abuse is suspected, it is important to us direct questions, such as "is anyone harming you?" Or "have you been confined against your will?" This questioning should occur in a private setting away from accompanying family members or caregivers |
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Defects Signaling Systemic Conditions: Faun Tail Nevus
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i. Tuft of hair over the spinal column
ii. Fauntail Nevus: associated with spina bifida occulta |
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Defects Signaling Systemic Conditions: Verrucous Nevi
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i. Warty lesion at birth or early childhood
ii. Verrucous Nevus: associated with skeletal, CNS or ocular abnormality |
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Defects Signaling Systemic Conditions: Café au lait Patches
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i. Flat, pigmented spots > 5mm
ii. Café au lait: associated with neurofibromatosis, pulmonary stenosis, etc |
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Defects Signaling Systemic Conditions: Port Wine Stain
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i. Large purpulish well demarcated lesions
ii. Port wine: if eye involved, consider glaucoma. Limbs or trunks: visceral vascular pathology, may effect bones, organs more prone to bleeding. |
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Defects Signaling Systemic Conditions: Supernumerary Nipple
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i. Accessory nipple along the mammary ridge
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The adipose tissue in the hypodermis serves to:
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generate heat and insulate
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Which cultural group has the lowest incidence of nevi?
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African Americans
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Transient mottling of the patient’s skin in a cool room is a common finding in:
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newborn infants
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Which nail change found on examination would be most alarming?
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A single dark band in a white adult
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Which decubitus ulcer stage indicates damage into the subcutaneous tissue?
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Stage III
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Which structure is the site of new nail growth
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Matrix
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Pale, shiny skin of the lower extremities may reflect
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systemic disease
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Which of the following is an “ABCD” characteristic of malignant melanoma?
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Asymmetric borders
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The nurse inspects an annular lesion. What type of additional lighting source should be used for further assessment?
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Wood’s lamp
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Small, less than 0.5-cm diameter, red-purple nonblanchable discolorations of the skin are:
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petechiae
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A flat, nonpalpable lesion is described as a macule if the diameter is
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less than 1 cm
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Assessment of poor hygiene, healed fractures with deformity, or unexplained trauma in older adults indicates:
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physical neglect
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The skin repairs epidermal wounds by:
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exaggerating cell replacement
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Unusual white areas on the skin may be due to:
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vitiligo
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Which of the following is a noncandidal fungal infection?
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Tinea corporis
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Sweat glands, hair, and nails are all formed from
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invaginations of epidermis into dermis
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You are conducting a preschool examination on a 5-year-old child. Which injury would most likely raise your suspicion that the child was being abused?
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Bruises in various stages of resolution over body soft tissues
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The characteristic that best differentiates psoriasis from other skin abnormalities is the:
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color of the scales
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