Assessing The Integumentary System Flashcards
1
Q
● Heaviest single organ of the body
● 16% of body weight
● Includes appendages such as hair follicles and sebaceous glands
A
Skin
2
Q
● Three layers: epidermis, dermis, subcutaneous layers
● Protect underlying structures from physical trauma and UV radiation
● Essential in maintaining body temperature, fluid and sensation
● Involved in absorption and excretion, immunity, and synthesis of vitamin D from the sun
A
Skin
3
Q
Layers of the Skin
A
- Epidermis
- Dermis
- Subcutaneous Layer
4
Q
Identify the Layer of Skin
● Outer visible layer
● Avascular
● Contains keratin
A
Epidermis
5
Q
Identify the Layer of Skin
● Made up of proteins and mucopolysaccharides
● Contains nerve tissues, blood vessels,
sweat and sebum glands, and hair follicles
A
Dermis
6
Q
Identify the Layer of Skin
● Made up of fatty connective tissue
A
Subcutaneous Layer
7
Q
● Made up of keratinized cells
● Grows from hair follicles supplied by blood vessels
● Types: Vellus and Terminal hair
● Provides protection by covering the scalp and filtering dust and debris away from the nose, ears, and eyes
A
Hair
8
Q
Types of Hair
A
- Vellus hair
- Terminal hair
9
Q
Identify the types of Hair
● Short, pale, and fine hair
A
Vellus hair
10
Q
Identify the types of Hair
● Dark and coarse
● Found on the scalp, brows, legs, axillae
and perineum
A
Terminal hair
11
Q
● Made up of hard, keratinized cells and grow from a nail root under the cuticle
● Protect the distal ends of the fingers and toes and aid in picking up objects
● Other structures: free edge, nailbed, lunula
● Vascular supply is on the nailbed; gives the nail a pink color
● Fingernails: grow approximately 0.1mm daily
● Toenails grow more slowly
A
Nails
12
Q
It has Eccrine glands and Apocrine glands
A
Sweat glands
13
Q
This gland is….
- Widely distributed, open directly onto
the skin surface
- Help control body temperature
A
Eccrine glands
14
Q
This gland is….
▪ found in the Axillary and genital regions
▪ surfaces into hair follicles
▪ Responsible for adult body odor due to
bacterial decomposition
A
Apocrine glands
15
Q
Gland that produce fatty substance secreted onto the skin surface through the hair follicles and lubricates the hair shaft
A
Sebaceous gland
16
Q
Interaction with other Body Systems:
- The Respiratory System
A
If respiration is impaired, alterations is the skin are most often evident through
the development of cyanosis
17
Q
Bluish discoloration of the skin, as hemoglobin becomes unsaturated with oxygen
A
CYANOSIS
18
Q
Respiratory System Fails Manifestations: Cyanosis
A
Peripheral and Central Cyanosis
19
Q
Respiratory System Fails Manifestations: Cyanosis
Occurs when O2 saturation is <80% and results in diffuse changes in the skin and mucous membranes
A
Central Cyanosis
20
Q
Respiratory System Fails Manifestations: Cyanosis
Occurs in response to decreased cardiac output Evident in areas of the body such as the nail beds and lips May also be evident when an individual is chilled
A
Peripheral Cyanosis
21
Q
Manifestations when Respiratory System Fails:
Loss of the normal angle between the nail and nail bed owing to bulbous swelling of the soft tissue of the terminal phalanx of a digit due severe and chronic cardiopulmonary diseases
A
Nail Clubbing
22
Q
Manifestations when Cardiovascular System Fails:
A
- Alterations can lead to circulatory impairment and changes in skin color and temperature which may develop Lesions, ulcerations, necrosis, and cyanosis
23
Q
Manifestations when Gastrointestinal System Fails:
A
body’s ability to excrete toxins is impaired and accumulation of toxins may become
evident in the skin
24
Q
Manifestations when Gastrointestinal System Fails:
- Yellowish discoloration of the skin due
to bile build-up secondary to impaired
bile secretion
A
Jaundice
25
Manifestations when Gastrointestinal System Fails:
- Lipid deposits in the skin due to altered
lipid metabolism
Xanthomas
26
Manifestations on skin when there is Vitamin A Deficiency
- abnormally dry,
scaly skin or membranes
Xerosis
27
Manifestations on skin when there is Vitamin A Deficiency
- hyperkeratosis of the skin manifested by red-brown follicular papules that are approximately 2-6mm in diameter, with a central keratotic spinous plug
Phrynoderma
28
Manifestations on skin when there is Riboflavin Deficiency
- chapping and
fissuring of the lips
Cheilosis
29
Manifestations on skin when there is Riboflavin Deficiency
- sore, red tongue
Glossitis
30
Manifestations on skin when there is Vitamin C Deficiency
- It results into purpura, petechiae, and
ecchymosis in the skin and splinter hemorrhages in the nails
Capillary fragility
31
Manifestations on skin when there is Vitamin C Deficiency
- Hair loss can affect just your scalp or your entire body, and it can be temporary or permanent
- can be the result of heredity, hormonal changes, medical conditions or a normal part of aging
Alopecia
32
Manifestations on skin when there is Vitamin C Deficiency
- can occur as a result of scurvy
Corkscrew hair
33
Manifestations on skin when there is Iron Deficiency
- vertical raised lines present on the nails
Longitudinal ridges on the nails
34
Manifestations on skin when there is Iron Deficiency
- spoonlike convexity of the nails
Koilonychia
35
Manifestations on skin when there is Iron Deficiency
Thinning of hair
36
Manifestations on skin when there is Iron Deficiency
- loss of pink color in the palmar creases on the
full open palms
Palmar crease pallor
37
Manifestations on skin when there is Protein Deficiency
- alternating horizontal bands of hypopigmentation of the hair
Flag sign
38
Manifestations on skin when there is Protein Deficiency
- dark, dry kin that splits open when stretched,
revealing pale areas between the cracks
Enamel paint skin
39
Manifestations when Urinary System Fails:
* Alteration in the renal function
may lead to toxin and fluid
build-up
40
Skin Manifestations when Urinary System Fails:
- Tiny, yellow-white urea crystals deposits on the skin resulting in a frosted appearance as sweat
evaporates
Uremic frost
41
Skin Manifestations when Urinary System Fails:
- Impaired renal function may result in fluid retention as manifested by edema
Edema
42
Manifestations when Neurological System Fails:
- place a person at risk for injury
and discomfort
43
Manifestations when Endocrine System Fails:
Alterations of the endocrine system may affect the skin in myriad ways
- Diabetes
- Thyroid Disease (Hypothyroidism or Hyperthyroidism)
- Adrenal Disease (Hypofunction (Addison’s
Disease) and Hyperfunction (Cushing’s Syndrome)
44
Thyroid Disease has two types
Hypothyroidism and Hyperthyroidism
45
Thyroid Disease Identify which type:
- The skin is often dry and cool and becomes puffy, with nonpitting edema. It may develop a yellow hue as carotene accumulates The hair becomes dull, brittle, and sparse
Hypothyroidism
46
Thyroid Disease Identify which type:
- The skin is warmer, sweatier, and smoother than usual The nails are thin and brittle and may separate from the nail plate The hair is fine and silky, with patchy hair loss
Hyperthyroidism
47
Adrenal Disease two types
Hypofunction (Addison’s Disease) and Hyperfunction (Cushing’s Syndrome)
48
Adrenal Disease Identify which type:
- Bronze discoloration of the skin
and alopecia
Hypofunction (Addison’s Disease)
49
Adrenal Disease Identify which type:
- Violaceous striae, facial acne, hirsutism, acanthosis nigricans
Hyperfunction (Cushing’s Syndrome)
50
Manifestations when Lymphatic/Immune
System Fails:
Impairments in the immune system may result in typical rashes or lesions
51
Skin Manifestations when Lymphatic/Immune
System Fails:
- exaggerated or inappropriate immunologic responses occurring in response to an antigen or allergen
Hypersensitivity reaction
52
Skin Manifestations when Lymphatic/Immune
System Fails:
- chronic (long-lasting) disease in which the immune system becomes overactive, causing skin cells to multiply too quickly
- Patches of skin become scaly and inflamed, most often on the scalp, elbows, or knees
Psoriasis
53
Skin Manifestations when Lymphatic/Immune
System Fails:
- when immune cells in your skin react to UV light sources, releasing chemicals that inflame your skin
Butterfly rash in Systemic Lupus Erythematosus
54
Collecting Subjective Data: GROWTHS
Ask if the patient is concerned about any new growths or rashes
* “Have you noticed any changes in your skin? Your hair? Your nails?
* “Have you had any rashes? Sores? Lumps? Itching?”
If the patient reports a new growth, pursue the patient’s personal and family history of skin cancer.
* Note the type, location, and date of any past skin cancer and ask
about regular self-skin examination and use of sunscreen
* Also ask “Has anyone in your family had a skin cancer removed? If
so, who? Do you know what type of skin cancer?”
55
Collecting Subjective Data: RASHES
Ask about itching – the most important symptom when assessing rashes
* Does the itching precede the rash or follow the rash?
* For itchy rashes, ask abut seasonal allergies with itching and watery eyes, asthma, and atopic dermatitis, often accompanied by rash on the inside of the elbows and knees in childhood
* Can the patient sleep all night or does itching wake up the patient?
Find out what type of moisturizer or over-the-counter products have been applied
Ask about dry skin, which can cause itching and rash
56
Collecting Subjective Data: HAIR LOSS
* Ask if there is hair thinning or hair shedding and, if so, where? (the most common causes of diffuse hair thinning are male and female pattern baldness)
* If shedding, does the hair come out at the roots or break along the hair shafts? (Hair shedding at the roots is common in telogen effluvium and alopecia areata. Hair breaks along the shaft suggest damage from hair care or tinea capitis)
* Ask about hair care practices like frequency of shampooing and use of dyes, chemical relaxers, or heating appliances
57
Collecting Subjective Data: Hair loss
- frontal hairline regression and thinning on
the posterior vertex
Male pattern hair loss
58
Collecting Subjective Data: Hair loss
- thinning that spreads from the crown down
without hairline regression
Female pattern hair loss
59
Collecting Subjective Data: Hair loss
- temporary hair loss due to the excessive shedding
of resting or telogen hair several months after a person experiences a traumatic event or stress
Telogen effluvium
60
Collecting Subjective Data: Hair loss
- an autoimmune disorder that results in unpredictable, patchy hair loss
Alopecia areata
61
Collecting Subjective Data: Hair loss
- fungal infection of the scalp that causes itchy,
scaly, bald patches on the head
Tinea capitis
62
Collecting Subjective Data: Nail changes
- a superficial infection of the proximal and lateral nail folds adjacent to the nail plate that arises from local trauma due to nail biting, manicuring or frequent immersion in water
Paronychia
63
Collecting Subjective Data: Nail changes
- a bulbous swelling of the soft tissue at the nail base, with the loss of the normal angle between the nail and the proximal nail fold. Seen in congenital heart disease, interstitial lung disease
and lung cancer
Nail clubbing
64
Collecting Subjective Data: Nail changes
- depression of the central nail with a “Christmas
tree” appearance from small horizontal depressions, resulting from repetitive trauma from
rubbing the index finger over the thumb or vice versa
Habit Tic deformity
65
Collecting Subjective Data: Nail changes
- increased pigmentation in the nail matrix,
leading to a streak as the nail grows out
Melanonychia
66
Collecting Subjective Data: Nail changes
- painless separation of the whitened opaque nail plate from the pinker translucent nail bed which may be caused bytrauma from excess manicuring,
psoriasis, fungal infection, and allergic reactions to nail cosmetics.
Onycholysis
67
Collecting Subjective Data: Nail changes
- a fungal infection of the nails that cause
discoloration, thickening, and separation from the nail bed
Onychomycosis
68
Collecting Subjective Data: Nail changes
- nail plate turns white with a ground-glass appearance, a distal band of reddish brown, and
obliteration of the lunula. Seen in liver disease, heart failure, and diabetes.
Terry nails
69
Collecting Subjective Data: Nail changes
- transverse depressions of the nail plates,
usually bilateral, resulting from temporary disruption of the proximal nail growth from systemic illness
Beau’s lines
70
Collecting Subjective Data: Nail changes
- punctuate depressions of the nail plate caused by
defective layering of the superficial nail plate by the proximal nail matrix. Usually associated with psoriasis
Pitting
71
Collecting Objective Data: PREPARING THE CLIENT
* Ask the client to remove all clothing and jewelry and put on an examination gown
* Ask to remove nail enamel, artificial nails, wigs, toupees, or hairpieces
* Have the client sit comfortably on the examination table or bled
* In assessing the skin on the buttocks and dorsal surfaces of the legs, the client may lie on her side or abdomen
* Ensure privacy and comfortability
* Sunlight is preferred, but a bright light can be used as well
* Wear gloves when palpating any lesions
* Clients from conservative religious groups may require the nurse to be the same sex as the client
72
Collecting Objective Data: EQUIPMENT
* Examination light
* Penlight
* Mirror
* Magnifying glass
* Centimeter ruler
* Gloves
* Wood’s lamp
* Examination gown or drape
* Braden Scale for Predicting Pressure
Sore Risk
* Pressure Ulcer Scale for Healing (PUSH) to measure pressure ulcer healing
73
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal general skin color.
Evenly colored skin tones without unusual prominent discolorations
74
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of general skin color.
- Pallor
- Cyanosis
- Jaundice
- Acanthosis nigricans
75
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of general skin color.
- Seen in arterial insufficiency, decreased blood
supply, and anemia
Pallor
76
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of general skin color.
- Roughening and darkening of skin in localized areas especially the posterior neck
Acanthosis nigricans
77
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of odors emanating from the skin.
Slight or no odor of perspiration depending on activity
78
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of odors emanating from the skin.
A strong odor of perspiration or foul odor may indicate disorder of sweat glandsor poor hygiene
79
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of color variations.
- Suntanned areas, freckles, or white patches known as vitiligo; albinism.
- Dark-skinned clients may have lighter-colored palms, soles, nail beds, and lips
- Freckle-like or dark streaks of pigmentation are also common in the sclera and nail beds of
dark-skinned clients
80
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of color variations.
- Rashes
- Erythema (skin redness and warmth) seen in inflammation, allergic reactions, or trauma
81
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of skin integrity.
Skin is intact, and there are no reddened areas
82
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of skin integrity.
Skin breakdown is initially noted as reddened area on the skin that may progress to serious and painful pressure ulcers
83
Identify which of the 4 stages of ulcers is being described
- The area looks red and feels warm to the touch. With darker skin, the area may have a blue or purple tint. The person may also complain that it burns, hurts, or itches.
Stage I
84
Identify which of the 4 stages of ulcers is being described
- The area looks more damaged and may have an open sore, scrape, or blister. The person complains of significant pain and the skin around the wound may be discolored.
Stage II
85
Identify which of the 4 stages of ulcers is being described
- The area has a crater-like appearance due to damage below the skin's surface.
Stage III
86
Identify which of the 4 stages of ulcers is being described
- The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage.
Stage IV
87
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of suspected fungus, shine
a Wood’s light on the lesion.
Lesion does not fluoresce
88
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of suspected fungus, shine
a Wood’s light on the lesion.
Blue-green fluorescence indicates fungal infection
89
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Normal Findings of skin lesions.
Note:
- Note color, shape and size. For very small lesions, use a magnifying glass
- Note its location, distribution, and configuration
- Measure the lesion with a centimetre ruler
Skin is smooth, without lesions. Stretch marks, healed scars, freckles, moles, or birthmarks are common findings. Freckles or moles may be scattered over the skin in no particular pattern.
90
PHYSICAL ASSESSMENT – SKIN (INSPECTION): Abnormal Findings of skin lesions.
Note:
- Note color, shape and size. For very small lesions, use a magnifying glass
- Note its location, distribution, and configuration
- Measure the lesion with a centimetre ruler
- Primary lesions
- Secondary lesions
- Vascular lesions
91
Identify the primary lesions being described
- small flat spot measuring <1cm
Macules
92
Identify the primary lesions being described
- larger flat spot measuring >1cm
Patches
93
Identify the primary lesions being described
- small raised spot measuring <1cm
Papule
94
Identify the primary lesions being described
- larger raised spot measuring >1cm
Plaque
95
Identify the primary lesions being described
- raised, fluid-filled, and small lesion measuring <1cm
Vesicle
96
Identify the primary lesions being described
- raised, fluid-filled, and large lesion measuring >1cm
Bulla
97
Identify the primary lesions being described
- small, palpable collection of neutrophils or
keratin that appears white
Pustules
98
Identify the primary lesions being described
- inflamed hair follicle
Furuncle
Notes: multiple furuncles together form a carbuncle
99
Identify the primary lesions being described
- larger and deeper than a papule
Nodule
100
Identify the primary lesions being described
- encapsulated collections of fluid or semisolid
Subcutaneous mass/cyst
101
Identify the primary lesions being described
- area of localized dermal edema that evanesces
within a period of 1-2 days
Wheal
102
Identify the primary lesions being described
- small, linear or serpiginous pathways in the
epidermis created by the scabies mite
Burrow
103
Identify the Secondary lesions being described
- loss of superficial epidermis that does not
extend to the dermis
Erosion
104
Identify the Secondary lesions being described
- skin mark left after healing of wound or
lesion that represents replacement by connective tissue of the injured tissue
Scar (Cicatrix)
105
Identify the Secondary lesions being described
- skin loss extending past epidermis with necrotic tissue loss
Ulcer
106
Identify the Secondary lesions being described
- linear crack in the skin that may extend to the dermis and may be painful
Fissure
107
Identify the Secondary lesions being described
- round red or purple macule that is 1-2mm in size. It is secondary to blood extravasation and associated with bleeding tendencies or emboli to skin
Petechia
108
Identify the Secondary lesions being described
- round or irregular macular lesion that is larger than a petechial lesion
Ecchymosis
109
Identify the Secondary lesions being described
- a localized collection of blood creating an elevated ecchymosis
Hematoma
110
Identify the Secondary lesions being described
- papular and round, red or purple lesion found
on the trunk or extremities. Normal age-related skin alteration
Cherry angioma
111
Identify the Secondary lesions being described
- red arteriole lesion with a central body with
radiating branches. Associated with liver disease, pregnancy, and vitamin B deficiency
Spider angioma
112
Identify the Secondary lesions being described
- bluish or red lesion with varying shape found on the legs and anterior chest. Associated with
varicosities
Telangiectasis (Venous star)
113
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess texture, Normal Findings
- Use the palmar surface of your three middle
fingers to palpate skin texture
Skin is smooth and even
114
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess texture, Abnormal Findings
- Use the palmar surface of your three middle
fingers to palpate skin texture
- Rough, flaky, dry skin is seen in hypothyroidism
- Obese clients often report dry itchy skin
115
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess thickness, Normal Findings
- If lesions are noted, put gloves on and palpate the lesion between the thumb and index finger for size, mobility, consistency, and tenderness. Observe for drainage or other characteristics
- Skin is normally thin but calluses (rough, thick sections of epidermis) are common on areas of the body that are exposed to constant pressure
- No lesions palpated
116
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess thickness, Abnormal Findings
- If lesions are noted, put gloves on and palpate the lesion between the thumb and index finger for size, mobility, consistency, and tenderness. Observe for drainage or other characteristics
- Very thin skin may be seen in clients with arterial insufficiency or those on steroid therapy
- Infected lesions may be tender to palpate. Nonmobile, fixed lesions may be cancer
117
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess moisture, Normal Findings
- Check under skin folds and in
unexposed areas
- Use the dorsal surfaces of the
hands
Skin surfaces vary from moist to dry depending on the area assessed. Recent activity or a
warm environment may cause increased moisture
118
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess moisture, Abnormal Findings
- Check under skin folds and in
unexposed areas
- Use the dorsal surfaces of the
hands
- Increased moisture or
diaphoresis may occur in
conditions such as fever or
hypothyroidism
- Decreased moisture occurs with dehydration or hypothyroidism
- Clammy skin is typical in shock or hypotension
119
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess Temperature, Normal Findings
Skin is normally a warm temperature
120
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess Temperature, Abnormal Findings
- Cold skin may accompany shock or hypotension.
- Cool skin may accompany arterial disease.
- Very warm skin may indicate a febrile state or
hyperthyroidism
121
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess mobility and skin turgor, Normal Findings
-Ask the client to lie down. Using two fingers,
gently pinch the skin over the clavicle.
Normally. The skin is mobile, with elasticity and returns to original shape quickly
122
refers to how easily the skin can be pinched.
Mobility
123
refers to the skin’s elasticity and how quickly the skin returns to its original shape after being pinched
Turgor
124
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess mobility and skin turgor, Abnormal Findings
-Ask the client to lie down. Using two fingers,
gently pinch the skin over the clavicle.
- Decreased mobility is seen with edema.
- Decreased turgor is seen in dehydration.
125
PHYSICAL ASSESSMENT – SKIN (PALPATION): assess to detect edema, Normal Findings
-Use your thumbs to press down on the skin of the feet or ankles to check for edema (swelling related o accumulation of fluid in the tissue)
Skin rebounds and does not remain indented when pressure is released
126
TYPES OF PERIPHERAL EDEMA
Non-pitting edema and Pitting edema
127
Identify which type of edema is being described
* Associated with lymphedema
* Caused by abnormal or blocked lymph vessels
* Usually bilateral
* No skin ulceration or pigmentation
Non-pitting edema
128
Identify which type of edema is being described
* Associated with chronic venous insufficiency
Pitting documented as:
1+ - slight pitting
2+ - deeper than 1+
3+ - noticeably deep pit; extremely looks larger
4+ - very deep pit; gross edema in extremity
* Usually unilateral
* Skin ulceration and pigmentation may be present
Pitting edema
129
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal general color and condition
Natural hair color as opposed to chemically colored hair, varies among clients from pale
blond to black to gray or white
130
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Abnormal general color and condition
- Nutritional deficiencies may cause patchy gray hair in some clients.
- Severe malnutrition may cause a copper-red hair color
131
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal Findings, At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions.
-Wear gloves if lesions are suspected
or if hygiene is poor
Scalp is clean and dry. Sparse dandruff may be visible. Hair is smooth and firm, somewhat
ecstatic
132
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Abnormal Findings, At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions.
-Wear gloves if lesions are suspected
or if hygiene is poor
- Excessive scaliness may indicate dermatitis.
- Raised lesions may indicate infections or tumor growth.
- Dull, dry hair may be seen with hypothyroidism and malnutrition.
- Poor hygiene may indicate a need for client teaching or assistance with activities of daily living
- Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease
- Infections of the hair follicle appear as pustules surrounded by erythema
133
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal Findings, amount and distribution of scalp, body, axillae, and pubic hair.
- Look for unusual growth elsewhere in the body
- Varying amounts of terminal hair cover the scalp, axillary, body, and pubic areas according to normal gender distribution.
- Fine vellus hair covers the entire body except for the soles, palms, lips, and nipples. Normal male pattern balding is symmetric
134
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Abnormal Findings, amount and distribution of scalp, body, axillae, and pubic hair.
- Look for unusual growth elsewhere in the body
- Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity,
hepatic or renal failure. It may also result from
chemotherapy or radiation therapy.
- Patchy hair loss may result from infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy.
- Hirsutism (facial hair on females) is a characteristic of Cushing’s disease and results from an imbalance of adrenal hormones or it may be a side effect of steroids
135
PHYSICAL ASSESSMENT – SCALP AND HAIR (INSPECTION & PALPATION): Normal Findings, nail grooming and cleanliness
Nails are clean and manicured
136
PHYSICAL ASSESSMENT – NAILS (INSPECTION): Abnormal Findings, nail grooming and cleanliness
Dirty, broken, or jagged fingernails may be seen with poor hygiene. They may also result from the client’s hobby or occupation
137
PHYSICAL ASSESSMENT – NAILS (INSPECTION): Normal Findings, nail color and markings
Pink tones should be seen. Longitudinal ridging is normal
138
PHYSICAL ASSESSMENT – NAILS (INSPECTION): Abnormal Findings, nail color and markings
- Pale or cyanotic nails may indicate hypoxia or anemia.
- Splinter hemorrhages may be caused by trauma.
- Beau’s lines occur after acute illness and eventually grow out.
- Yellow discoloration may be seen in fungal infections or psoriasis.
- Nail pitting is also common in
psoriasis
139
PHYSICAL ASSESSMENT – NAILS (INSPECTION): Normal Findings, shape of nails
There is normally a 160-degree angle between the nail base and the skin
140
PHYSICAL ASSESSMENT – NAILS (INSPECTION): Abnormal Findings, shape of nails
Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia
141
PHYSICAL ASSESSMENT – NAILS (PALPATION): Normal Findings, assess texture
Nails are hard and basically immobile
142
PHYSICAL ASSESSMENT – NAILS (PALPATION): Abnormal Findings, assess texture
Thickened nails (especially toenails) may be caused by decreased circulation, and is
also seen in onychomycosis.
143
PHYSICAL ASSESSMENT – NAILS (PALPATION): Normal Findings, assess texture and consistency, noting whether nail plate is attached to nail bed
Nails are smooth and firm; nails plate should be firmly attached to nail bed
144
PHYSICAL ASSESSMENT – NAILS (PALPATION): Abnormal Findings, assess texture and consistency, noting whether nail plate is attached to nail bed
Paronychia (inflammation) indicates local infection. Detachment of nail plate from
nail bed (onycholysis) is seen in infections or trauma.
145
PHYSICAL ASSESSMENT – NAILS (PALPATION): Normal Findings, Test capillary refill
- pressing the nail tip briefly and watching for color change
Pink tone returns immediately to blanched nail beds when pressure is released
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PHYSICAL ASSESSMENT – NAILS (PALPATION): Abnormal Findings, Test capillary refill
- pressing the nail tip briefly and watching for color change
There is slow (greater than 2 seconds) capillary nail bed refill (return of pink tone) with respiratory or cardiovascular diseases that cause hypoxia.
