Health assessment

• Skin


  The largest and most visible organ of the body which makes up about 15 – 20% of body weight
• Skin


  • Plays a critical role in a person's physical and mental health
  • Assessment can reveal a variety of conditions including changes in oxygenation, circulation, nutrition, local tissue damage and hydration

  
• Functions of skin


  • Protection
  • Homeostasis
  • Thermoregulation
  • Sensory Perception
  • Absorption
  • Excretion
  • Vitamin D synthesis
• Epidermis


  The outer layer of skin, composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum
• Dermis


  The inner layer of skin, with dermal papillae connecting it to the epidermis
• Sebaceous glands


  Attached to hair follicles and secrete sebum that waterproofs the hair and skin
• Sweat glands


  Two types: eccrine and apocrine. Eccrine glands secrete sweat for thermoregulation. Apocrine glands secrete a milky sweat and produce body odor
• Subcutaneous tissue


  Loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles. Stores fat, provides insulation, cushions organs, and contains vascular pathways
• Physical assessment equipment/materials


  • Strong direct lighting
  • Small centimeter ruler
  • Penlight
  • Gloves
• Physical assessment examination techniques

  • Inspection
  • Palpation
• Color


  Observation of skin tones, which should be congruent with the client's stated race
• Normal skin color findings

  • Skin pigmentation ranges in tone from ivory or light pink to ruddy pink in light-skinned individuals and from light to deep brown or olive in dark-skinned people
• Abnormal skin color findings

  • Cyanosis (bluish discoloration)
  • Pallor (decrease in color, paleness)
  • Loss of pigmentation (vitiligo)
  • Jaundice (yellow discoloration)
  • Erythema (intense redness)
  • Tan-brown (increased melanin)

  
• Moisture


  Refers to the wetness and oiliness of the skin, which can reveal body fluid imbalances, changes in the skin's environment, and regulation of body temperature
• Normal moisture findings


  • Smooth and dry with minimal perspiration and oiliness
• Abnormal moisture findings


  • Dullness, excessive dryness, crusting, flaking, scaling, overly moist and cool
• Temperature


  Depends on the amount of blood circulating through the dermis, indicating increases or decreases in blood flow
• Normal temperature findings


  • Uniformly warm
• Abnormal temperature findings


  • Generalized warmth in fever and hyperthyroidism
  • Coolness in hypothyroidism
  • Local warmth in inflammation, cellulitis and pressure ulcer
• Texture


  Refers to the character of the skin's surface and the feel of deeper portions, which may change due to trauma, surgical wounds or lesions
• Normal texture findings


  • Smooth, soft, even and flexible in children and adults
• Abnormal texture findings


  • Scar or hardening (recent skin injury), tenderness or localized areas of induration or hardening due to repeated IM/SQ injections, roughness in hypothyroidism
• Mobility and turgor


  Turgor is the skin's elasticity, which can be diminished by edema or dehydration. Mobility is the ease in lifting up the skin when pinching and the speed with which it returns into place.
• Normal mobility and turgor findings


  • Skin lifts easily and snaps back immediately to its resting position
• Abnormal mobility and turgor findings

  • Skin stays or tented when turgor is poor (e.g. dehydration), decreased mobility in edema, scleroderma
• Vascularity


  The circulation of the skin affects the appearance of superficial blood vessels, which become fragile with aging
• Abnormal vascularity findings


  • Petechiae: tiny, pin-point sized, red purple spots on the skin caused by small hemorrhages in the skin layers

  
• Edema


  The collection of fluid in underlying tissues that separate the skin's surface from pigmented and vascular layers, resulting in a balanced appearance

  
• Types of edema


  • Dependent edema (appears in the feet, ankles, and sacrum)
  • Pitting edema (residual indentation left by the fingers with pressure when the fluid is displaced from the underlying tissues)
• Pitting edema grading


  + 1 = mild pitting, slight indentation, no perceptible swelling

  + 2 = moderate pitting, indentation rapidly 4 mm

  + 3 = deep pitting, indentation remains for a short time, area affected looks swollen, 6mm

  + 4 = very deep pitting, indentation lasts a long time, area affected is very swollen, 8 mm
• Lesions


  The skin is normally free of lesions, except common freckles or age-related changes. Inspect the skin for any lesions and describe the findings about any lesion in an orderly fashion: location, distribution, size, arrangement, color, configuration, secondary changes, and presence of drainage.
• Lesions


  • Vesicle
  • Bulla
  • Pustule on palm: Pustular psoriasis
• Nails


  The condition of the nails reflects the individual's overall state of health, indicating nutritional, respiratory and psychological status, occupation and level of self-care
• Normal nail findings


  • Transparent, smooth, well-rounded, convex with a nail bed angle of about 160 degrees. The surrounding cuticles are smooth, intact, and without inflammation.
• Abnormal nail findings


  • Clubbing (increase angle and softening of the nail bed due to chronic oxygenation problems)
  • Cyanosis (bluish or purplish cast to the nail bed)
  • Anemia (white cast or pallor)
  • Paronychia (inflammation of proximal and lateral nail folds due to trauma and local infection)
  • Onycholysis (painless separation of the nail plate from the nail bed)
  • Terry's nails (nail plate color mostly whitish with a distal band of reddish brown due to aging, liver cirrhosis, CHF, NIDDM)
  • White spots (Leukonychia)
  • Transverse white lines (Mee's lines)
  • Beau's lines (transverse depression in nails associated with acute severe illness, nail injury)
  • Psoriasis (small pits in the nails, marked nail thickening, onycholysis, circumscribed yellowish tan discoloration)
  • Koilonychia (Spoon nail, concave curves due to iron-deficiency anemia, syphilis or use of strong detergents)
  • Splinter hemorrhages (red or brown linear streak in nail bed due to minor trauma, sub acute bacterial endocarditis, trichinosis)
• Hair and scalp


  Hair distribution patterns are examined for symmetry and distribution according to age and sexual development. The scalp contains sebaceous glands that produce sebum, a mixture of keratin, fat and cellulose debris which forms a moist, oily acidic film that protects the skin surface.

  
• Types of hair


  • Terminal hair (long, coarse, thick, easily visible on the scalp, axilla, pubic areas, beard in men)
  • Vellus hair (small, soft, tiny hairs covering the whole body except the palms and soles, the dorsum of the distal fingers, the umbilicus, the glans penis and inside the labia)

  
• Normal hair findings


  • Resilient and evenly distributed, scalp hair may be coarse or fine, curly or straight and should be shiny
• Abnormal hair findings


  • Hirsutism (excess body hair due to hormonal disorders)
  • Alopecia (hair loss or thinning related to genetic predisposition to baldness, chemotherapy)
  • Dry, brittle hair (due to protein-deficient diet, febrile illness, aging, excessive use of shampoo)

  
• Forms of alopecia


  • Alopecia areata (well-defined bald patches, usually self-limited and recurrent)
  • Alopecia totalis (loss of all scalp hair, usually permanent)
  • Alopecia universalis (total loss of hair on all parts of the body)
  • Toxic alopecia (patchy asymmetric balding accompanying severe illness or chemotherapy, with regrowth after illness or discontinuation of toxin)