NCM 101

• Hair is composed of keratin and can be fine (vellus hair) or darker and thicker (terminal hair)
• Sebaceous glands produce sebum through hair follicles, making the skin oily and preventing water loss
• Sweat glands include eccrine glands with smaller, coiled tubules opening to the skin surface, and apocrine glands that are larger and open to hair follicles, mainly located in the axillae and genital area
• Nails are composed of keratin and have a clear appearance with a highly vascular bed of epithelial cells underneath
• The skin is the largest organ of the body, providing protection from the environment, regulating temperature, synthesizing vitamin D, storing fat and blood, excreting waste, and enabling sensation
• The epidermis consists of the stratum germinativum (basal cell layer) where mitosis occurs, and the stratum corneum where cells die and convert their cytoplasm to keratin, undergoing constant shedding. The dermis is mostly connective tissue providing support and nourishment to the epidermis, while the subcutaneous layer (hypodermis) consists mostly of fat providing protection, insulation, and a caloric source
• Developmental considerations in infants include lanugo, thinner skin, Mongolian spots, and physiological jaundice. Adolescents may experience acne, while pregnancy can lead to linea nigra, chloasma, and striae gravidarum. Aging results in thinning of the stratum corneum, loss of collagen, elastin, and fat, and a decrease in sebaceous and sweat glands
• History taking should include inquiries about skin diseases, familial predispositions, allergies, tattoos, birthmarks, changes in pigmentation, moles, pruritus, dryness, and medications. Physical examination should assess color, temperature, moisture, and any abnormalities like hair loss or growth
• Skin Assessment:

  • Temperature: check with dorsa of hands, hyperthyroidism may cause an increase in temperature
  • Moisture: diaphoresis may occur during fever or exercise, dehydration can be observed by dry mucous membranes in the mouth and cracked skin
  • Mobility and Turgor: mobility is the ease of skin rising when pinched, turgor is returning back to its place, slow turgor can indicate dehydration, "tenting" if severe dehydration
  • Lesions: any traumatic or pathological change in the skin, describe using ABCDE, also noting location and exudate, roll nodule gently between fingers to assess depth, ultraviolet light is used if fungal infection suspected (Wood’s lamp)
• Skin Assessment - shapes:

  • Annular: circular, beginning in the center and spreading to the periphery (ringworm)
  • Polycyclic: annular lesions that grow together
  • Confluent: lesions run together (hives)
  • Discrete: individual lesions that remain separate
  • Grouped: clusters of lesions (contact dermatitis)
  • Gyrate: twisted, coiled
  • Target: concentric rings of color
  • Linear: scratch-like, stripe
  • Zosteriform: follow nerve route (shingles)
• Primary vs. Secondary Skin Lesions:

  • Primary skin lesions: variations in color or texture present at birth or acquired during a person's lifetime, such as moles, warts, acne, hives, or environmental agents
  • Secondary skin lesions: changes in the skin that result from primary skin lesions, either as a natural progression or as a result of a person manipulating a primary lesion
• Primary Skin Lesions:

  • Macule: color change and less than 1 cm, may be darker or lighter, e.g., freckles, flat nevi, petechiae
  • Patch: color change and greater than 1 cm, e.g., Mongolian spots, vitiligo
  • Papule: elevated lesion less than 1 cm in diameter, due to elevation in epidermis, e.g., wart, elevated nevus
  • Plaque: elevation greater than 1 cm in diameter, e.g., psoriasis
  • Nodule: elevated solid greater than 1 cm, extending deeper into dermis
  • Tumor: greater than a few cm in diameter, may be firm or soft
  • Wheal: superficial, raised, transient, and erythematous lesion, e.g., mosquito bite, allergic reaction
  • Cyst: encapsulated fluid-filled cavity in dermis or subcutaneous layer
  • Vesicle: elevated cavity containing free fluid, clear, less than 1 cm diameter, e.g., herpes simplex, varicella zoster
  • Bulla: larger than 1 cm in diameter, superficial in epidermis, thin-walled, e.g., blisters, burns
  • Pustule: pus in cavity, e.g., impetigo, acne
• Secondary Skin Lesions:

  • Crust: thick, dry exudate after rupture or drying up of vesicle or pustule, e.g., impetigo, scab following abrasion
  • Scale: dry or greasy flakes of skin resulting from shedding of excess keratin cells, e.g., psoriasis, eczema
  • Fissure: linear cracks extending into dermis
  • Ulcer: deep depression extending into dermis, may bleed, leave a scar
  • Excoriation: self-inflicted abrasion often from scratching
  • Lichenification: tightly packed papules from prolonged intense scratching
  • Keloid: hypertrophic scar, cannot be removed surgically, more common in black people
• Hair and Scalp:

  • Ringworm may develop in the scalp of school-age children
  • Abnormalities in amounts and location of hair can be attributed to hormonal problems
  • Hirsutism: excess body hair
  • Abnormal conditions of hair: tinea capitis (scalp ringworm), toxic alopecia, folliculitis, furuncle, abscess
• Structure of a Nail:

  • Nails are good indicators of respiratory system health
  • Nail base: normal is about 160°, clubbing is the decrease of the angle of the nail base (<160°) that occurs as a result of respiratory insufficiency, spongy nails
  • Consistency: variant thickness may suggest malnutrition, thickening of nails is a sign of arterial insufficiency
  • Color: note any pigmentations, cyanotic nail beds indicate poor peripheral circulation
  • Capillary refill: indicator of peripheral circulation, normal time is less than 1-2 seconds and is indicated as "brisk," "sluggish" if greater than 2 seconds
• Vascular Lesions - Hemangiomas:

  • Port-Wine Stain (Nevus Flammeus): flat macular patch of mature capillaries, benign
  • Strawberry Mark (Immature hemangioma): raised bright red area, usually disappears by age 7
  • Cavernous Hemangioma
• Teaching Self-Exam

  Pressure Ulcers:

  • Stage I: a reddened area on the skin that, when pressed, is "non-blanchable," indicating the development of a pressure ulcer
  • Stage II: the skin blisters or forms an open sore, the area around the sore may be red and irritated
  • Stage III: the skin breakdown looks like a crater with damage to the tissue below the skin
  • Stage IV: the pressure ulcer has become deep with damage to the muscle, bone, tendons, and joints
• Braden Scale:

  • Sensory Perception
  • Activity
  • Mobility
  • Skin Moisture
  • Friction and Shear
  • Nutrition
  • Range 4-23, the lower the score the higher the risk, 18 or less indicates high risk in older adults