Health Assessment (NUR 224) King Saud University College of Nursing Health Assessment (NUR 224) The Skin, Hair, and Nails

Anatomy and Physiology Major function of skin is to keep the body in homeostasis Provides boundaries for body fluid Protects underlying tissues from microorganisms, harmful substances, and radiation Modulates body temperature Synthesizes vitamin D Heaviest single organ in body 16% of body weight

Anatomy and Physiology (cont.) Three layers Epidermis Dermis Subcutaneous tissue Hair, nails, and sebaceous and sweat glands are appendages of skin

Anatomy and Physiology (cont.) Hair Vellus hair – short, fine, less pigmentation Terminal hair – coarser, pigmented (scalp/eyebrows) Nails - protect distal ends of fingers/toes Sebaceous glands – present all surfaces except palms/soles; produce a fatty substance secreted onto skin surface through hair follicles Sweat glands Eccrine glands – widely distributed, open directly onto skin surface, help control body temperature Apocrine glands – found in axilla and groin, stimulated by emotional stress

The Health History Common or concerning symptoms Ask the patient Hair loss Rash Moles Ask the patient “Have you noticed any changes in your skin or your hair?” “Have you noticed any moles that have changed size, shape, color, or sensation?” “Have you noticed any new moles?”

Health Promotion and Counseling Clinicians play an important role in educating patients Early detection of suspicious moles Protective measures for skin care Hazards of excessive sun exposure Skin cancers are most common cancers in some countries. Most prevalent on hands, neck, and head

HARMM Risk Factors for Melanoma History of previous melanoma Age over 50 Regular dermatologist absent Mole changing Male gender

Additional Risk Factors for Melanoma ≥50 common moles Red or light hair Heavy sun exposure (especially severe childhood sunburns) Light eye or skin color (especially freckles/burns easily) Family history of melanoma

ABCDE: Screening Moles for Possible Melanoma A for asymmetry B for irregular borders, especially ragged, notched, or blurred C for variation or change in color, especially blue or black D for diameter ≥6 mm or different from other moles, especially changing, itching, or bleeding E for elevation or enlargement

Techniques of Examination Examination of the skin, hair, and nails begins with the general survey of the patient Make sure the patient wears a gown Drape appropriately to facilitate close inspection of hair, anterior and posterior surfaces of body, palms and soles, and webspaces Inspect entire skin surface in good light Preferably in natural light (or artificial light that resembles natural) Artificial light often distorts colors

Techniques of Examination (cont.) Inspect and palpate skin Note characteristics of: Color Moisture Temperature Texture Mobility and turgor Lesions

Techniques of Examination (cont.) Color Patients often notice change in color before physician Look for increased pigmentation, loss of pigmentation Look for redness, pallor, cyanosis, and yellowing Red color of oxyhemoglobin best assessed at fingertips, lips, and mucous membranes In dark-skinned people, palms and soles For central cyanosis, look in lips, oral mucosa, and tongue Jaundice - sclera

Techniques of Examination (cont.) Moisture Dryness, sweating, and oiliness Temperature Use back of fingertips Identify warmth or coolness of skin Texture Roughness or smoothness.

Techniques of Examination (cont.) Mobility and turgor Lift fold of skin Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor)

Techniques of Examination (cont.) Lesions Note characteristics Anatomic location and distribution Patterns and shapes Type of lesion (macules, papules, nevi, vesicles) Color

Techniques of Examination (cont.) Skin lesions in context Whenever you see a skin lesion, look it up in a well-illustrated textbook of dermatology To arrive at a dermatologic diagnosis, consider the type of lesions, location, and distribution, along with the patient’s history and physical

Examples of skin lesions

Techniques of Examination (cont.) Hair Inspect and palpate Note quantity, distribution, and texture

Techniques of Examination (cont.) Nails Inspect and palpate fingernails/toenails Note color and shape Note lesions Longitudinal bands of pigment may be a normal finding in people with darker skin

Evaluating the Bedbound Patient People confined to bed are particularly susceptible to skin damage and ulceration Pressure sores result when sustained compression obliterates arteriolar and capillary blood flow to the skin Assess these patients by carefully inspecting the skin that overlies the sacrum, buttocks, greater trochanters, knees, and heels.

Evaluating the Bedbound Patient Roll patient onto one side to see sacrum and buttocks

Recording the Physical Examination Initially you may use sentences to describe findings; later you will use phrases Examples: “Color good. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymoses.” “Marked facial pallor, with circuoral cyanosis. Palms cold and moist. Cyanosis in nail beds of fingers and toes. One raised blue-black nevus, 1x2 cm, with irregular border on right forearm. No rash.”

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