Lecture Integumentary Presentation 09

Chapter 12

Skin, Hair, and Nails Ella Yu (VL)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails



Structure and Function



Subjective Data—Health History Questions



Objective Data—The Physical Exam



Abnormal Findings

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-1

Chapter 12 Skin, Hair, and Nails

Structure and Function 

Skin – three layers 1. Epidermis – Stratum germinativum or basal cell layer • Fibrous protein keratine • Melanocytes (same amount)- melanin (varies) – Stratum corneum or horny cell layer • Dead keratinized cells

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

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Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Structure and Function 

Skin – three layers 2. Dermis – – – –

Connective tissue or collagen Elastic tissue Nerves, sensory receptors, blood vessel, lymphatic Appendages from the dermis

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-2

Chapter 12 Skin, Hair, and Nails

Structure and Function 

Skin – three layers 1. Subcutaneous layer – – – – – –

Adipose tissue Lobules of fat cells Stores fat for the energy Provides insulation foe temperature control Protection- soft cushioning effect mobility

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

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Epidermal appendages 1. Hair – – – – – –

Threads of keratine Hair shaft (visible projecting part) Hair root (embedded in the follicles Bulb matrix (cell production) Arrector pili muscle- goose skin 2 types: vellus and terminal

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

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Epidermal appendages 1. Sebaceous glands – – –

Sebum Lubricate skin and hair Retards water loss from the skin

2. Sweat glands – –

Eccrine glands Apocrine glands

3. Nails – –

Hard plates of keratine Nail matrix

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Function of the Skin 

Protection



Prevents penetration

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Perception

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Temperature regulation

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Identification

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Communication

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Wound repair

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Absorption and excretion

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Production of vitamin D

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-3

Chapter 12 Skin, Hair, and Nails

Subjective Data— Health History Questions 

Previous history of skin disease (allergies, hives, psoriasis, or eczema)

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Pruritus

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Excessive bruising

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Rash or lesion

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Medications

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Change in mole

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Change in pigmentation (size or color)

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Hair loss

Excessive dryness or moisture

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Change in nails

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Environmental or occupational hazards

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Self-care behaviors



– Seborrhea – xerosis Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-4

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam 

Preparation – External variables that influence skin color



Equipment needed – – – – –

Strong direct lighting Small centimeter ruler Penlight Gloves For special procedures • Wood’s light • Magnifying glass • Materials for laboratory tests: potassium hydroxide (KOH), glass slide

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-5

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Skin—Inspect and Palpate 

Color – General pigmentation • Vitiligo • Freckles, mole, birthmark • Abnormal: ABCDE – Widespread color change • Pallor- anemia • Erythema- carbon monoxide poisoning, hyperemia • Cyanosis- increased amount of unoxygenated hemoglobin • Jaundice- increase serum bilirubin

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-6

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Promoting Health and Self-Care 

Teach skin self-examination, using the ABCDE rule A—asymmetry B—border C—color D—diameter E—elevation and enlargement

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-12

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Skin—Inspect and Palpate, cont. 

Temperature – Hypothermia: general/ localized – Hyperthermia



Moisture – Diaphoresis- profuse perspiration – Dehydration

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-7

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Skin—Inspect and Palpate, cont. 

Texture (smooth and firm)

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Thickness (callus)

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Edema (fluid accumulating in the intracellular space) – 1+ , 2+, 3+, 4+

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Mobility and turgor – – – –

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(anterior chest under clavicle) Elasticity of skin Mobility- ease of rising (oedema) Turgor- ability to return to place promptly when release (dehydation)

Vascularity or bruising (abuse- different stage of healing) – Cherry angioma – tattoo

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-8

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Skin—Inspect and Palpate, cont. 

Lesions – – – – – – –

Primary or secondary Color Elevation Pattern or shape Size Location and distribution on body Exudate

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-9

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont.

Skin—Inspect and Palpate, cont. 

Lesions – Wood’s light detects fluorescing lesions • Lesions with blue-green fluorescence indicate fungal infection, such as tinea capitis (scalp ringworm) – Potassium Hydroxide (KOH) preparation helps dignose superficial fungal infection as it can dissolve nonfungal skin debris

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-9

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Hair—Inspect and Palpate 

Color



Texture



Distribution



Lesions – Seborrhoea – Nits of lice

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-10

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Nails—Inspect and Palpate 

Shape and contour – Profile sign



Consistency

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Color – Capillary refill

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-11

Chapter 12 Skin, Hair, and Nails

Objective Data— The Physical Exam, cont. Promoting Health and Self-Care 

Teach skin self-examination, using the ABCDE rule A—asymmetry B—border C—color D—diameter E—elevation and enlargement

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-12

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Common Shapes and Configurations of Lesions 

Annular or circular

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Confluent

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Discrete

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Grouped

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Gyrate

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Target or iris

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Linear

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Polycyclic

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Zosteriform

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-13

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Gyrate

Linear Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Grouped

Zosteriform

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Primary and Secondary Skin Lesions Primary skin lesions

– – – – – – –

Macule Papule Patch Plaque Nodule Wheal Tumor

– – – – –

Urticaria (hives) Vesicle Cyst Bulla Pustule

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Secondary skin lesions

– – – – –

Crust Scale Fissure Erosion Ulcer

– – – – –

Excoriation Scar Atrophic scar Lichenification Keloid

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Primary Skin lesion



A lesion develops on previously unaltered skin

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Macule Flat and circumscribed Less than 1 cm

Papule Solid, elevated Less than 1 cm

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Nodule Solid, elevated Larger than 1 cm Extend to dermis

Wheal -superficail, -Erythematous --mosquito bite

Pustule - pus - acne

Vesicle -Up to 1 cm -Clear serum -Chicken pox Crust Cyst -Herpes simplex -Dry on abrasion - Fluid filled in dermis/ Scab following Subcutaneous layer Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. abrasion Copyright © 2003, Elsevier Science (USA). All rights reserved.

Secondary skin lesion 

A lesion change over time or changes because of a factor such as scratching or infection

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Scale -psoriasis

Excoriation -superficial, sometimes crusted -self inflicted abrasion -Scratches from intense itching -insect bits, scabies

Fissure -linear crack -extend to dermis -Athelet’s foot Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Ulcer -deeper depression to dermis -Pressure sore

Chapter 12 Skin, Hair, and Nails

Scar

Atrophic scar

Lichenification Keloid -intense scratching Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. -excsess scar tissue Copyright © 2003, Elsevier Science (USA). All rights reserved.

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Chapter 12 Skin, Hair, and Nails



Hemangiomas

Abnormal Findings Vascular Lesions

– Port-wine stain (nevus flammeus) – Strawberry mark (immature hemangioma) – Cavernous hemangioma (mature)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-15

Chapter 12 Skin, Hair, and Nails

Abnormal Findings Vascular Lesions



Telangiectases

– Spider or star angioma – Venous lake

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-15

Chapter 12 Skin, Hair, and Nails

Abnormal Findings Vascular Lesions

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Purpuric lesions – Petechiae – Purpura

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Lesions due to trauma or abuse – Pattern injury – Hematoma – Ecchymosis (bruise)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-15

Chapter 12 Skin, Hair, and Nails

Abnormal Findings Vascular Lesions



Lesions due to trauma or abuse – Pattern injury – Hematoma – Ecchymosis (bruise)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-15

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Common Skin Lesions in Children 

Diaper dermatitis

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Interigo (candidiasis)

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Impetigo

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Atopic dermatitis (eczema)

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Measles (rubeola)

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German measles (rubella)

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Chickenpox (varicella)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-16

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chicken pox

Psoriasis Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Common Skin Lesions 

Primary contact dermatitis

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Allergic drug reaction

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Tinea corporis (ringworm of the body)

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Tinea pedis (ringworm of the foot)

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Psoriasis

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Tinea versicolor

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Labial herpes simplex (cold sores)

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Herpes zoster (shingles)



Erythema migrans of Lyme disease

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-17

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Malignant Skin Lesions 

Basal cell carcinoma

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Squamous cell carcinoma



Malignant melanoma

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-18

Squamous cell carcinoma

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Malignant Melanoma

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Skin Lesions Associated with AIDS 

Epidemic Kaposi’s sarcoma – Patch stage – Plaque stage – Advanced disease

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-19

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Infectious Disease as a Biological Weapon 

Anthrax



Smallpox (variola major)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-20

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Abnormal Conditions of Hair 

Seborrheic dermatitis (cradle cap)



Tinea capitis (scalp ringworm)



Toxic alopecia

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Alopecia areata

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Traumatic alopecia, traction alopecia

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Trichotillomania

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Pediculosis capitis (head lice)

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Folliculitis

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Hirsutism

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Furuncle and abscess

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

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Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Abnormal Conditions of the Nails 

Koilonychia (spoon nails)

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Paronychia

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Beau’s line

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Splinter hemorrhages

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Late clubbing

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Onycholysis

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Habit-tic dystrophy

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Pitting

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-22

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 12 Skin, Hair, and Nails

Abnormal Findings

Abnormal Conditions of the Nails

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 12-22