School of Nursing
Christopher W. Blackwell, Ph.D., ARNP-C
Assistant Professor, School of Nursing
College of Health & Public Affairs
University of Central Florida
NGR 5003: Advanced Health Assessment & Diagnostic Reasoning
Unit Four: Dermatological, Breasts, & Axillae :
· Basic assessment of the dermatological system, breasts, and axillae
· Advanced assessment of the dermatological system, breasts, and axillae
· Assessment findings of abnormal presentations in the dermatological system, breasts, and axillae
· Differential diagnoses of the dermatological system, breasts, and axillae
· Advanced Clinical reasoning: A case study approach
advanced assessment of skin, hair, and nails
LEARNING OBJECTIVEs
1. Conduct a history related to skin, hair, and nails.
2. Discuss examination techniques for skin, hair, and nails.
3. Identify normal age and condition variations of skin, hair, and nails.
4. Recognize findings that deviate from expected findings.
5. Relate symptoms or clinical findings to common pathologic conditions.
Outline for Chapter 8: Skin, Hair, and Nails
Anatomy and Physiology
· Skin provides an elastic, rugged, self-regenerating, protective covering for the body.
· The skin and its appendages are our primary physical presentation to the world.
· Skin structure and physiologic processes perform the following integral functions:
· Protect against microbial and foreign substance invasion and minor physical trauma
· Retard body fluid loss by providing a mechanical barrier
· Regulate body temperature through radiation, conduction, convection, and evaporation
· Provide sensory perception via free nerve endings and specialized receptors
· Produce vitamin D from precursors in the skin
· Contribute to blood pressure regulation through constriction of skin blood vessels
· Repair surface wounds by exaggerating the normal process of cell replacement
· Excrete sweat, urea, and lactic acid
· Express emotions
Epidermis
· The epidermis, the outermost part of the skin, consists of two major layers:
· The stratum corium provides protection. It is composed of dead squamous cells containing keratin.
· The cellular stratum synthesizes keratin cells.
· The basement membrane, below the cellular stratum, connects the epidermis to the dermis.
· Stratum lucidum is found only in thicker skin of palms and soles.
· The epidermis is avascular and gets nutrition from the dermis.
Dermis
· The dermis is vascular connective tissue. It separates the epidermis from the cutaneous adipose tissue.
· Elastin, collagen, and reticulin fibers provide strength and stability.
· The dermis contains sensory and autonomic motor nerve fibers.
Hypodermis
· The hypodermis consists of connective tissue containing fatty cells. Adipose tissue generates heat and provides insulation and caloric reserve.
Appendages
· Appendages are formed from the epidermis invaginating into the dermis.
· Eccrine sweat glands secrete water and regulate body temperature.
· Apocrine glands are deeper glands that respond to emotional stimuli by secreting odorless white fluid.
· Sebaceous glands secrete sebum as regulated by hormonal levels.
· Hair consists of epidermal cells in the dermal layers. Vellus hair is short, fine, soft, and nonpigmented. Terminal hair is coarser, longer, thicker, and usually pigmented.
· Nails are hard plates of keratin. The pink color is from vascular beds under the plate. The cuticle is stratum corium that covers the nail root. The paronychium is soft tissue surrounding nail border.
Age- and Condition-Related Variations
· Infants and children. The skin of young people is smoother than that of adults and lacks terminal hair. After birth, there is variable desquamation. Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth. Lanugo hair is found on shoulders and back. It is shed in about 2 weeks after birth. Head hair is shed by 2 to 3 months and is replaced by more permanent hair. Eccrine sweat glands function after the first month of life. Inactive apocrine glands make the skin less oily.
· Adolescents. During puberty, the apocrine glands enlarge and become active. Sebaceous glands increase sebum production, which gives an oily appearance and predisposes the individual to acne. Coarse terminal hair appears in axillae and pubic area.
· Pregnant women. During pregnancy, increased blood flow results from peripheral vasodilation and increased capillaries. Sweat and sebaceous gland activity increases. Skin thickens and fat is deposited in subdermal layers. Increased pigmentation occurs from hormonal changes.
· Older adults. With age, sebaceous and sweat gland activity decreases. Epidermis thins and flattens. Vascularity in dermis decreases and becomes less elastic. Cutaneous tissue decreases. Gray hair occurs from a decrease in the number of functioning melanocytes. Density and rate of hair growth decline. Nail growth slows and nails become thicker, brittle, and yellow. They also develop ridges and are prone to split.
Review of Related History
History of Present Illness
· Skin. Patients with skin problems should be asked about changes in skin such as warts, moles, or lesions, as well as temporal sequence, symptoms, and location of any skin occurrence. Associated symptoms and factors, such as high temperature, exposure to drugs, and travel history should be listed. Patient’s response to the problem and any home treatment should be noted. Patient’s perception of the cause of the condition should also be explored.
· Hair. Data relevant to a hair condition include the following: changes in hair patterns, occurrence or recurrence of problem, associated symptoms and factors (e.g., itching or drug exposures), dietary habits, patient’s reaction to the problem, and factors affecting condition.
· Nails. Patients with nail conditions should be asked about the following: any changes in their nails, symptoms (e.g., pain or swelling), temporal sequence of the problem, recent exposures, and things making condition better or worse.
Past Medical History
· Skin. Data relevant to the past medical history include previous skin problems (e.g., skin reactions or lesions), exposure to sunlight, changes in sensory stimuli, and systemic diseases affecting skin.
· Hair. Patients with hair conditions should be questioned about any previous hair problems (e.g., loss of hair), pattern changes, and systemic problems (e.g., thyroid disease).
· Nails. Past medical history should include data on previous nail problems (e.g., infections) and systemic problems (e.g., cardiac conditions) that could influence nail condition.
Family History
· Relevant data include current or past dermatologic diseases of family members, allergic hereditary diseases or skin disorders, and familial hair patterns.
Personal and Social History
· Pertinent data include skin care habits (e.g., cosmetic use and sun exposure), hair care habits (e.g., cleansing routine, as well as the use of any coloring or permanent products), nail care habits, use of medications, exposure to environmental or occupational hazards, and any recent psychologic or physiologic stress.
Age- and Condition-Related Variations
· Infants. Relevant data include feeding and diaper history, types of clothing, products used to wash clothes, bath practices, habits of dressing the infant, and the home environment.
· Children. Explore eating patterns, disease exposure, allergic disorders and reactions, previous skin injury, hair manipulation, and nail-biting habits.
· Pregnant women. Pertinent data include weeks of gestation or postpartum, hygienic practices, presence of prior skin lesions, and effects of pregnancy on previous skin lesions.
· Older adults. Ask older patients about changes in touch sensation, chronic itching, susceptibility to skin infections, changes or slowness in healing, history of falling, diabetes, vascular diseases, or hair loss.
See Risk Factors: Basal and Squamous Cell Carcinoma (p. 214) and Risk Factors: Melanoma (p. 215).
Examination and Findings
Summary of Examination—Skin, Hair, and NailsSkin
· Ensure adequate lighting.
· Assess skin contour, symmetry, color.
· View exposed and unexposed areas.
· Describe lesions according to characteristics, exudates, location, and distribution.
· Use flashlight to see color, elevation, and borders of lesions.
· Use a Wood’s lamp to detect the presence of fungal infection.
· Smell skin odors.
· Feel skin for moisture, temperature, texture, turgor, and mobility.
· Use dorsal surface of hands and fingers to palpate skin temperature.
· View cysts and masses.
Hair
· Assess color, distribution, and quantity of hair.
· Palpate texture.
· Note any hair loss, inflammation, or scarring.
Nails
· Note nail color, length, configuration, angle at the base, and symmetry.
· Observe nail folds for signs of infection, warts, cysts, or tumors.
· Squeeze nail to test adherence.
Summary of Skin, Hair, and Nail Findings
Variations / Normal
Findings / Typical
Variations / Findings Associated
with Disorders /
Adults / Thinnest skin is on eyelids. Thickest is on soles, palms, and elbows. Color is uniform, except in sun-exposed areas.
Skin temperature is even
Texture is smooth, soft, and even.
Skin is resilient. Scalp hair is shiny, smooth, and resilient.
Nail color is a variation of pink.
Nail edges are smooth and rounded. / Callused areas are yellow. Skin striae, freckles, birth marks, nevi, and melasma may be present.
Freckling of buccal cavity, gums, and tongue is present in some dark-skinned persons.
Color hues in dark- skinned persons are best seen in the sclera, mucosa, and nail beds.
Lips and gums are bluish in dark-skinned persons.
Infants and children / Newborn skin may be red.
Vernix caseosa is a normal birth covering.
Newborn nails may need to be trimmed to prevent scratching. / At birth, generalized lanugo suggests prematurity.
Physiologic jaundice is common.
Primary irritant or eczematous dermatitis may cause localized lesions.
Skin roughness may result from clothing, coldness, or soap.
Nail shape and opacity vary.
Pigment deposits may be present in dark-skinned persons. Darkened nails may result from antimalarial drug treatment or shoe trauma.
White spots in nail plate may result from mild trauma. Peeling nails may occur with water exposure.
Longitudinal ridging and beading are common. / Newborn skin distortions suggest masses, nodules, or tumors. The presence of patches, erythema, scaling, crusts, fissures, vesicles, lesions, and skin irregularities in children requires investigation.
Localized redness suggests inflammation.
Hemorrhage results from injury, steroids, or systemic disorders. Fluid-filled lesions show red glow with transillumination. Generalized lesions may indicate a systemic disorder, allergy, or genetic disorder. Annular patterns are associated with pityriasis rosea, tinea corporis and cruris, urticaria.
Connective tissue diseases lead to changes in skin mobility. Asymmetric hair loss in males may indicate a pathologic condition. Female alopecia or female hirsutism in male hair patterns may indicate pathology. Yellow nails occur with psoriasis, fungal infections, and respiratory disease. Darkened nails can result from Candida infection or hyperbilirubinemia. Green-black nails are caused by Pseudomonas infection or subungual hematoma. Nail depression and clubbing occur from systemic disease. Separation of nail plate from bed results from psoriasis and infections.
Adolescents / Adolescents are prone to acne from hormonal changes. Terminal hair develops at puberty.
Body odors develop. / Perspiration may result from anxiety or obesity.
Nail hygiene is a clue about self-care and emotional and social levels. / Fine or coarse hair and hair loss may be due to thyroid conditions.
Pregnant women / During pregnancy, there are peripheral vasodilation and increased capillaries.
Sweat and sebaceous gland activity increases.
Palmar erythema., a diffuse redness that covers the entire palmar surface or the thenar and hypothenar eminence, is a common finding in pregnancy and usually disappears after delivery. / Increased pigmentations occur from hormonal changes. Pregnancy causes striae, vascular spiders, and acne in some.
Vascular spiders and hemangiomas that are present may increase in size.
Older adults / Skin becomes more transparent, pale, dry, wrinkled, and hyperpigmented with aging.
Hair becomes coarser with age.
Nails thicken and become more brittle with age. / Graying hair occurs as a result of a decrease in functioning melanocytes.
Balding patterns in men are genetically determined. Several types of lesions may be present:
Cherry angiomas
Sebaceous hyperplasia
Cutaneous tags/horns
Senile lentigines / Stasis dermatitis and solar keratosis are skin conditions that affect older adults. Cardiac disease influences nail conditions.
· See Box 8-1: Patient Instructions for Skin Self-Examination (p. 174).
· See cultural differences discussed in the Physical Variations boxes (pp. 171, 176, 177, 191, 200, and 202) and Box 8-2: Cutaneous Manifestations of Traditional Health Practices (p. 176).
· See the Mnemonics box for melanoma (p. 215).
· See Table 8-1 (p. 177), Table 8-2 (p. 177) and Table 8-3 (p. 178), which describe nevi, moles, and cutaneous color changes.
· See Figure 8-7 (p. 180), Table 8-4 (pp. 183 to 185), Table 8-5 (pp. 186 to 188), and Figure 8-15 (p. 193) for skin lesion and nail drawings.
· See Figures 8-10, 8-11, and 8-12 (p. 190) for various patterns of skin lesions.
· See Box 8-5: Expected Color Changes in the Newborn (p. 195); Risk Factors box: Hyperbilirubinemia in the Newborn (p. 195); Box 8-6: Skin Lesions: External Clues to Internal Problems (p. 196); and Table 8-7: Estimating Dehydration (p. 199).
· See Box 8-7: Staging of Decubitus Ulcers (p. 202).
· See Table 8-6: Morphologic Characteristics of Skin Lesions (p. 189).
Advanced assessment of breasts and axillae
LEARNING OBJECTIVEs
1. Conduct a history related to the breasts and axillae.
2. Discuss examination techniques for the breasts and axillae.
3. Identify normal age and condition variations to the breasts and axillae.
4. Recognize findings that deviate from expected findings.
5. Relate symptoms or clinical findings to common pathologic conditions.
Outline for Chapter 16: Breasts and Axillae
Anatomy and Physiology
· The breasts are paired mammary glands located on the anterior chest wall, superficial to the pectoralis major and serratus anterior muscles. In women, the breast extends from the second or third rib to the sixth or seventh rib, and from the sternal margin to the midaxillary line. The nipple is located in the center, surrounded by the areola.
· The female breast is composed of glandular and fibrous tissue (which provides support for the breast) and fat (subcutaneous and retromammary) in proportions that vary with age, genetic predisposition, nutritional status, and pregnancy.
· The glandular tissue of the breast is arranged into lobes, each composed of lobules of milk-producing acini cells that empty into lactiferous ducts during lactation.
· Vascular supply to the breast is primarily through branches of the internal mammary and the lateral thoracic artery.