NSG6020 Week 9 Integumentary and Musculoskeletal Systems

NSG6020 Week 9 Integumentary and Musculoskeletal Systems

NSG6020 Week 9 Integumentary and Musculoskeletal SystemsWeek 9 Lectures
The Integumentary and Musculoskeletal Systems
The Skin:
The skin is our largest organ. The average adult has approximately 20 square feet of surface area to
provide protection from outside stressors and adapt to environmental situations such as heat and cold.
The skin has two layers: the dermis and the epidermis. The epidermis is the thin, tough outer layer. It is
our first line of defense. The dermis, made mostly of collagen, provides elasticity and assists the dermis
in resisting tears or injuries.
Hair was once a necessary tool for humans, providing protection from cold, heat, or trauma. Many
cultures believe hair is necessary or preferred as part of psychological and cosmetic values. Hair is
actually threads of keratin that grow in cycles. Each hair has a different rest/grow cycle so that certain
hairs are always growing while others are dormant.
The nails are hard layers or plates of keratin, found on the fingers and toes. The color of the nail is a
reflection of the underlying nail bed.
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Development Notes – The Skin:
Newborns to Adolescents
The newborn is covered in lanugo, or fine downy hair that is eventually replaced by fine vellus hair
several months after birth. Vernix caseosa may cover the newborn or can be found in the body creases
at birth. Scalp hair may or may not be present at birth. The scalp hair is usually soft and is quickly lost at
the temples and occiput.
The skin of the newborn is thin and smooth but more permeable than the skin of an adult. It is easier for
the newborn to lose fluid and become dehydrated. Sebum is the source of milia and cradle cap in some
infants. The sweat glands function at a low level throughout childhood and impair the ability to respond
to heat or fever. The infant is more susceptible to cold as the subcutaneous tissue is minimal and the
skin cannot shiver effectively.
As the child ages, the skin produces additional pigment, becomes thicker, hair growth speeds up, and
the skin is better lubricated. Pubertal changes include development of the sweat glands to respond to
heat and emotional distress, i.e., sweaty palms. Acne develops in response to an increase in oilier skin.
Pregnant Females
Hormonal changes create hyperpigmentation around the areolae, nipples, and vulva. A linea nigra may
be found in the midline of the abdomen. Chloasma or rash of pregnancy may be found across the face.
The rapid skin expansion often results in striae gravidarum. This may be found on the abdomen, thighs,
or breasts.
The Older Adult
The skin is the visible reminder of the aging process. As the patient ages, the skin loses elasticity and
becomes wrinkled, dry, and paper thin. The slightest injury will leave senile purpura, or dark red
blotches on the skin. The hair may lose melanocytes and become gray or white. The texture of the hair
may be thin and fine. The thinning of the pubic and axillary hair can be attributed to the gradual
decrease in testosterone. The older female loses estrogen, which allows testosterone to be the
dominant unopposed hormone. The presence of testosterone without estrogen promotes the growth of
facial hair in the older female.
Transcultural Considerations – The Skin:
Hair care for different cultures should be considered. African American hair texture tends to be fragile
and requires specific care. The scalp and hair are dry and should be gently brushed, combed, and oiled
daily. Examine the condition of the hair of any culture for insight into self-care, nutrition, and general
health. If adequate nutrition and self-care has not been met, the hair tends to be dry, brittle, and fragile.
Hair loss is common in thyroid disorders.
The Musculoskeletal System:
As you know, the toe bone is connected to the foot bone, the foot bone is connected to the leg bone,
the leg bone is connected to the knee bone, and so on. The musculoskeletal system is responsible for
our upright ambulation, body support, and for movement. The musculoskeletal system also provides
protection for vital organs, and the bone marrow produces red blood cells and provides storage for
essential minerals such as calcium and phosphorus.
Our skeleton system has 206 bones, which are connected by ligaments. Muscles should be almost half of
our body weight, each connected to the bones by tendons. The bones, muscles, ligaments, and tendons
allow movement in the following directions: flexion, extensions, abduction, adduction, pronation,
supination, circumduction, inversion, eversion, rotation, protraction, retraction, elevation, and
depression.
This week will cover the assessment techniques and specific developmental changes for the
musculoskeletal system.
The temporal mandibular joint (TMJ) allows movement of the jaw for speaking and chewing. The TMJ
allows opening and closing (hinge action), protrusion and retraction (gliding), and side-to-side
movement of the lower jaw.
The 33 vertebrae that constitute the spinal column can be palpated down the midline of the back. There
are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae in the human skeletal
system. C7 and T1 are most visible and located at the base of the neck. T7 and T8 are normally found at
the inferior angle of the scapula. Imagine a line across the highest point of the iliac crests; this should
estimate the level of L4. Imagine a line from the two symmetric dimples that overlie the posterior
superior iliac spines for S2. If you viewed the spinal column from a lateral aspect, you would see the 4
normal curvatures of the spine. The cervical and lumbar curves are concave while the thoracic and
sacrococcygeal are convex. The spine can flex forward, extend backwards, rotate, and abduct, or move
side to side.
The shoulder joins the humerus to the scapula. The glenohumeral joint is supported by four muscles and
tendons that make up the rotator cuff. You can palpate the acromion process or the tip of the scapula at
the top of the shoulder. This should feel like a very firm bump or knob. The greater tubercle of the
humerus is located down and over from the acromion process followed by the coracoids process of the
scapula on the medial aspect of the shoulder.
The elbow articulates the humerus, radius, and ulna. The elbow provides hinge action for flexion and
extension of the ulna and radius. The olecranon bursa is situated between the olecranon process and
the skin. The medial and lateral epicondyles of the humerus as well as the olecranon process of the ulna
are palpable on examination of the elbow. The radius and ulna allow pronation and supination of the
hand and forearm.
Over half of the bones in the human skeleton are located in the hands and feet. The radiocarpal joint
joins the radius to the carpal bones at the thumb. This joint is palpable at the dorsum of the wrist. The
midcarpal joint is the articulation of the two parallel rows of carpal bones. This joint allows for flexion,
extension, and some rotational movements. The metacarpophalangeal and interphalangeal joints allow
flexion and extension of the fingers.
The hip articulates the acetabulum and the head of the femur. You may palpate the iliac crest from the
anterior superior iliac spine to the posterior. The ischial tuberosity is found under the gluteus maximus
muscle and may be palpable when the hip is flexed. The greater trochanter is found below the iliac crest
and in between the superior iliac spine and ischial tuberosity. The greater trochanter may be palpated
when the patient is standing. It should feel like a flat depression on the upper lateral aspect of the thigh.
Patient girth and mobility may affect palpation of these landmarks.
The knee is the articulation of the femur, the tibia, and the patella. The knee is the largest joint in the
body, providing flexion and extension of the lower extremity. The synovial membrane forms a pouch or
sac at the superior border of the patella (suprapatellar pouch). This pouch may extend as far as 6
centimeters behind the quadriceps muscle. The medial and lateral menisci provide cushion between the
tibia and femur. The cruciate ligaments cross inside the knee, providing control of rotation, anterior and
posterior stability. The collateral ligaments connect the knee joint at both sides providing medial and
lateral stability. The collateral ligaments help prevent dislocation. The prepatellar bursa is found
between the patella and the skin and is usually palpable. The infrapatellar fat pad is found below the
patella behind the patellar ligament. Landmarks of the knee begin with the quadriceps muscle on the
anterior and lateral thigh. The four heads of this large muscle move into a common tendon that travels
downwards to enclose the patella. The tendon inserts down on the tibial tuberosity, which is palpable as
a bony prominence in the midline just below the patella. The lateral and medial condyles of the tibia
may be palpated as the knee is moved side to side. The medial and lateral epicondyles of the femur are
superior on either side of the patella.
The ankle articulates the tibia, fibula, and talus; a hinge joint that allows dorsiflexion and plantar flexion.
The medial malleolus and the lateral malleolus are the two bony landmarks on either side of the ankle.
The medial and lateral ligaments provide lateral stability of the ankle. The subtalar joint, below the
ankle, allows inversion and eversion of the foot. Weight bearing is distributed between the heads of the
metatarsals and the calcaneus or heel.
Developmental Notes across the Lifespan – The Musculoskeletal System
Infants and Children
The fetus has developed a cartilage skeleton by 3 months gestation. The cartilage gradually ossifies
during the remaining gestational period, followed by rapid bone growth immediately after birth. Bone
growth continues at a steady rate until adolescence, at which time another growth spurt occurs.
Long bones grow by length and width. The epiphyses or growth plates see longitudinal growth, whereas
bony tissue that is deposited around the bone shaft provides width. The last epiphysis closes around age
20 years. Prior to that time, any injury to the ends of the long bones puts the child at risk for bone
deformity.
At birth, there is only a single curve of the spine. At age 3 to 4 months, the anterior cervical curve
develops as the baby begins to lift its head. At age 12 to 18 months, the toddler who is learning to walk
develops the anterior curve in the lumbar region.
The Pregnant Female
The pregnant female undergoes numerous changes in the body during the gestational period. These
changes include increased mobility of the joints and relaxation of ligaments and tendons. The most
visible change in posture is the lordosis of the spine. The lordosis allows for the growing fetus by shifting
the weight back onto the lower extremities and placing increased pressure on the low back musculature.
This can trigger low back pain in many pregnant females. The cervical spine may flex forward and the
shoulders gradually slump in response to the lordosis. These changes can create pressure on the ulnar
and median nerves in the third trimester, leading to pregnancy induced carpal tunnel syndrome.
The Older Adult
Resorption of bone (loss of bone matrix) occurs more rapidly than bone deposition (bone growth) in the
older adult. The result is a loss of bone density or osteoporosis. The early loss of bone is osteopenia.
Females are more likely to have osteoporosis than males and more so in Caucasians than African
Americans. Asians have higher risk of osteoporosis than Caucasians. Risk factors for osteoporosis include
age, postmenopausal state, prior or current history of tobacco use, race, small bone frame, female sex,
and family history of osteoporosis. Males who have low testosterone, small bone frame, and history or
current use of tobacco products are at higher risk of developing osteoporosis.
Height is lost from osteoporotic changes in the vertebral column. Kyphosis, or Dowager’s hump, of the
thoracic spine may be seen in males and females alike. This is a complication of osteoporosis.
Bone mineral densities should be ordered with vertebral fracture assessment scores in order to evaluate
the level of bone loss. Vitamin D levels should be checked, with > 15 ng/dl being the goal for ages 4
years and up. This would be a minimum of 400 international units (IU) daily. It may be acquired through
dietary measures or supplements (http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/).
History – Integumentary and Musculoskeletal
Integumentary History of Present Illness (Subjective Data)
Ask about previous skin conditions or problems. What was the problem? When did it happen? How long
did you have the skin problem? How was it treated? Was the treatment successful? Has it recurred? Any
personal and/or family history of allergies or skin problems? Do you have any known environmental or
medical allergies? Do you have any birthmarks or tattoos? Are there any lesions that you are concerned
about today?
Have you noticed any changes in your skin color? How about changes in moles? Include itching,
bleeding, or change in color or size. When did this start? Do you have sores that will not heal?
Have you noticed any dryness to your skin? How about skin texture changes? Does this seem to be
seasonal? Do you find that you have more itching with this dryness? How severe is the itching? Does it
awaken you at night? Where are the dry spots or itching located? Are there any recent changes in your
lotions, soap, detergent, medications, etc.? Have you tried any prescription or over-the-counter (OTC)
medications for the problem? Did these items help?
Have you noticed any bruising? Where have you noticed the bruises? Do you know how the bruises
were inflicted? How long have you had these bruises?
Do you have a skin rash or lesion? When did you first notice the rash or lesion? Where is it located?
Does anything make it better or worse? Any itching associated with the rash or lesion? What color or
colors is the rash or lesion? Has the rash or lesion spread to other areas?
Ask the patient to describe the color and shape, and if there is any drainage. Does anyone else in his or
her family have a similar problem? Have they recently traveled, including camping, or taken part in
outdoor sports/activities? Have they used any new detergents, soaps, lotions, powders, or makeup?
Have they tried new medication or foods, or acquired a new pet? Does stress affect the rash at all?
How? Does anything make the rash better or worse? Ask specifically about OTC treatments as well as
prescriptions. Are there any associated signs and symptoms such as sinus problems, cough, or fever?
Any new stressors that you are aware of?
If you have not asked already, inquire about current medications, both prescription and OTC. Some
generic medications may have changed manufacturers and now have a different color. A dye change
may trigger an allergic reaction. Ask how long the patient has been taking each medication. Inquire
about change in shape, color, or texture of the nails.
Are you exposed to chemicals or other irritants at your work? Do you have any hobbies that might use
irritants such as painting, household repairs, furniture refinishing, gardening, farming, or automotive
work?
Ask specifically about sun exposure. This should include all forms of ultraviolet rays, such as tanning
beds. Do you use a sunscreen? What strength? How often and to what parts of the body do you apply
sunscreen? A minimum of 30 sunscreen protection factor (SPF) should be applied liberally to all exposed
areas of the body. Repeat at least every 2 hours while outside and after water activities. Are there any
recent insect bites? This includes ant bites, bees, ticks, mosquitoes, horseflies, etc.
Have you worked outside, walked in a wooded area, or been exposed to plants or animals recently? Did
you notice the rash before or after this activity?
What is your daily routine for skin, nail, and hair care? What type of products do you use? How often do
you have a manicure or pedicure? Do you have this done at a salon or at home? Do you check your skin
for changes? How often? Do you have annual examinations by a health care provider? Do you see a
dermatologist?
Infants and Children
Ask the parents if there are any birthmarks that they have noticed. Did the child have problems with
blueness at birth? How long did this last? Do they remember the child’s Apgar score at birth?
Did the infant experience jaundice? What day did the jaundice occur? How was it treated?
Are there any rashes or sores? Have you noticed any triggers for the rashes or sores? What was the last
food or drink that you introduced? When was the new item(s) introduced?
Have you noticed a diaper rash? Is this a constant problem or intermittent? What do you treat the
diaper rash with? Is it effective? What type of diapers do you use? How do you clean the baby when you
change the diaper? Have you changed diaper brands, soaps, lotions, or creams recently? What effect did
these changes have on the rash?
Tell me about bumps or bruises that you have noticed on your child. How did these occur? How long
have they been present? Any burns or other trauma? How did these happen? How have you treated
them? Keep in mind warning signs of physical abuse but also the normal bumps and bruises of a toddler.
Common findings in child abuse are straight lines from whippings, hand- or finger-shaped bruises,
cigarette burns, and bruising above the knees or elbows.
Do you know if the child has been exposed to lice, scabies, impetigo, chicken pox, measles, or scarlet
fever? How about irritating plants, such as poison oak or poison ivy?
Are immunizations up to date?
Have you noticed any repetitive habits, such as hair twisting or twirling, nail biting, or rubbing of the skin
or the head on the mattress?
How much sun exposure does your child have? What SPF sunscreen do you use? Tell me how you apply
the sunscreen. How often do you reapply the sunscreen? Has the child ever had sunburn? How did you
treat the sunburn?
Adolescents
Have you had problems with acne? How did you treat it? How long have you had problems with your
acne? How do you feel about the acne? Have you tried prescription or OTC medications for acne? What
kind, when, and what were the results? What is your daily skin care routine?
The Older Adult
Tell me about any skin changes you have noticed over the past 6 to 12 months. Have you found that it
takes longer for sores to heal? Do you have any sores right now? Have you had any itching or skin pain?
Have you had any changes in your feet, including itching or bunions? Have you had to change shoes
because of discomfort or irritations?
Do you have a history of diabetes, peripheral vascular disease, or frequent falls?
Tell me about your daily skin care routine. What products do you use? How often do you bathe? Do you
take a shower, bath, or “sponge bath”? Older adults may not bathe daily due to an increase in dry skin
or to physical limitations.
Musculoskeletal History of Present Illness (Subjective Data)
Joints
Do you have any pain or problems with your joints? Which ones; is it on either side or just one side?
Describe the pain: Dull, aching, throbbing, shooting, brief, nagging, sharp, dull, or stiff? On a scale of 1 to
10, with 1 being the least pain you have ever had and 10 being the worst pain ever, what is your pain
level now and at the height of the pain episode?
When did this pain begin? How long does it last? Does it occur at a particular time of day? How often do
you experience this pain? Are there any triggers or alleviating factors? Does rest or position change
help? Do you take any OTC or prescription medications for pain? Do these help? Have you tried
elevating the part, applying heat and or ice, or splinting/wrapping?
Have you noticed any fever, chills, rash, sore throat, repetitive activity, or recent trauma?
Are your joints stiff? Have you noticed any heat, redness, or swelling of your joints?
Are you limited in movement of any joints? Which ones? Does any activity give you difficulty?
Muscles
Do you have any problems with your muscles, such as pain or cramping? Which muscles?
If pain is noted in the calf muscles: Does the pain occur with walking? Does it resolve with rest? Have
you noticed any fever, chills, or other flu-like symptoms?
What medications, both prescription and OTC, are you currently taking? When was your last dose?
Some prescription and OTC medications can cause muscle cramps and myalgias. Be alert for
hypokalemia, hypocalcemia, and hypomagnesium. This may be related to dehydration, a result of crash
dieting, medication induced, etc.
Have you noticed any “weakness” of your muscles? If so, where? How long has it been present? Have
you noticed a change in the size of your muscles?
Bones
Do you have any bone pain? Where? How long have you had this pain? Does movement change the
pain? If so, how? Does anything specific make the pain better or worse? Have you tried any medications
including OTC medicines? What were the results?
Have you had any injuries to your bones? When, and which bones? What was the treatment? Do you
have any deformities? Does the deformity affect a joint and its mobility? Any previous sprains or strains?
Which part of the body? How was the sprain or strain treated?
Have any of your previous injuries caused lingering problems? Any limitations of your daily activities due
to the previous injury or pain?
Do you have any back pain? Show me where your back hurts. Does the pain radiate? Where? Describe
the pain: Is it shooting, dull, aching, stabbing, etc.? Have you noticed any numbness or tingling of the
lower extremities? Do you limp? Does the limp go away after you walk a short distance or does it
persist?
Functional Assessment
Ask specifically about activities of daily living. First, ask the general category; then, if a positive response
is elicited, inquire about each activity in the category. Does your joint or muscle problem cause
problems with:
Bathing: Getting in and out of the tub, turning the faucets?
Toileting: Urinating, having a bowel movement, getting on or off the toilet without assistance, cleaning
or wiping yourself?
Dressing: Fastening buttons, zipping a zipper, fastening a necklace or button behind your neck, pulling
your dress or sweater over your head, pulling up your pants, putting on your socks, tying your shoes,
finding shoes that fit comfortably?
Grooming: Shaving, brushing hair or fixing hair, brushing teeth, applying makeup?
Eating: Preparing food or meals, pouring liquids, cutting up foods, getting the food to your mouth,
drinking?
Mobility: Walking, walking up or down stairs, getting in or out of beds, getting out of the house?
Communicating: Talking, using the phone, writing, using the computer?
Ask the patient about his or her self-care activities. Does the patient follow an exercise routine? What is
the program and how often is it followed (length of time and number of days per week)? Does his or her
job involve lifting or repetitive motions? Has the patient tried anything to improve the work station and
alleviate stressors?
If you have not already asked, inquire about medications, both prescription and OTC. If antiinflammatory drugs are used, ask about gastrointestinal upset or irritation from the medications.
Inquire about self-esteem concerns. Chronic pain and/or disability can lead to depression and selfisolation.
Infants and Children
Did your baby experience any trauma during labor and delivery that you are aware of? Were forceps
used to deliver the infant? Was the baby born headfirst at delivery? Difficult or traumatic deliveries can
result in fractures, such as clavicular or humeral fractures.
Did the infant require extra care immediately after birth, such as resuscitation or oxygen? Anoxic injury
can cause hypotonia of the muscles. If cardiac compressions were required, rib cage injuries may be
present.
Did your baby achieve the suggested motor skill milestones as your other children or as compared to
national standards? Did your pediatrician discuss these milestones with you?
Has your child had any broken bones, sprains, or dislocations? How were these injuries treated? Are
there any residual problems?
Have you noticed any bony deformities on your child? Where? How about curving of the spine or pants
that fit “unevenly”? Are the feet shaped “normally”? Have you sought treatment for these problems?
Has your child been screened for scoliosis?
Adolescents
Do or have you participated in sports at school? How often do you play? Do you have to have special
equipment to play? Tell me about the equipment. Do you have a training program for this sport?
How do you warm up before playing a sport? Do you have a “cool down” session?
What do you do if you get hurt? Have you been hurt before? What happened?
How do you fit in sports with your other school activities? Does playing sports affect your homework or
school grades?
The Older Adult
Use your functional assessment questions for the older adult. You should also ask about the following:
Have you experienced any change in weakness over the past six months or year?
Have you noticed any increase in falls or gait changes in the past 12 months?
Do you use a cane, walker, or rolling walker to help you get around?
Physical Exam – Integumentary and Musculoskeletal Systems
The Integumentary System – Physical Exam
You should integrate the skin exam throughout the physical exam process, instead of making it a
separate part. Lift and open clothing that cover parts of skin in order to thoroughly examine the skin.
Remove shoes and socks to inspect the feet, check pulses, and evaluate nail bed and sensation as the
last part of the examination.
Your patient may present with a specific skin complaint. This would prompt a focused or regional skin
examination. Your first look at the area in question should be conducted standing back from a short
distance, then move in for a closer inspection.
Inspection and Palpation
Note the skin tone, color, and lesions. This would include moles, birthmarks, and freckles. Moles may be
tan to dark brown in color, and flat or raised. Birthmarks are tan to brown in color, appear flat, and may
be irregular in shape. Freckles are brown, flat macules that are found on sun-exposed skin.
The ABCDE danger signs of skin lesions should be kept in mind during the examination.
Asymmetry of a pigmented lesion (not round or oval)
Border irregularity (look for raised borders, notching, scalloping, ragged edges, and poorly defined
or blurred margins)
Color variation (tan, black, brown, blue, red, white, or combination of colors)
Diameter of 6 millimeters or more (the size of the end of a pencil eraser)
Elevation and enlargement (change in size; new nevi or lesion; new itching, burning, or bleeding)
Note any widespread color changes over the body. Is this an expected finding or not? Dark-skinned
patients should have their oral mucosa, sclera, nail beds, and palmar and plantar areas assessed for
color changes.
Pallor may be triggered by extreme stress or shock, anemia, or arterial insufficiency. For dark-skinned
patients, the skin may be more lackluster and have a yellowish, ashen, or gray appearance. Check the
oral mucosa, sclera, nail beds, and palmar and plantar areas for changes as well.
Erythema is an expected response to fever, localized inflammation, and as emotional responses such as
blushing or anger. Erythema is a response to rosacea as well. The patient with rosacea can experience
involuntary flushing of the face without triggers or maintain a constant ruddiness of the facial skin. You
should palpate for suspected erythema in the dark-skinned patient, as the erythema may not be readily
visible. The inflamed skin is firm and may feel warmer and taut to palpation.
Cyanosis indicates decreased perfusion. Cyanosis is a predictable factor but may be a nonspecific
finding. The anemic patient may not demonstrate cyanosis but still have hypoxia due to lack of
hemoglobin. Mediterranean descendants may have a bluish coloration of the lips as a normal finding.
Change in level of consciousness, respiratory distress, extreme fatigue, slurring of speech, and other
symptoms may indicate cyanosis in the dark-skinned person.
Jaundice is noted when bilirubin levels are elevated in the bloodstream. Jaundice is not a normal finding
unless it is physiologic jaundice in the newborn. Jaundice can be first noted at the junction of the hard
and soft palates, and then the sclera. Dark-skinned patients may have yellow subconjunctival fatty
deposits that should not be confused with true jaundice. Scleral jaundice will be present up to the iris.
Calluses on the palmar and plantar surfaces may appear yellow and should not be taken as a sign of
jaundice. If possible, evaluate the skin in natural daylight for the best assessment of jaundice.
The skin should feel warm and equal bilateral, fairly smooth to touch. Hands and feet may feel slightly
cooler than other areas.
Diaphoresis may be present if the patient has a high metabolic rate from fever or strenuous activity.
Strenuous activity can be walking or even breathing if the patient is acutely ill.
Edema may be present and should be graded on the following scale:
 1+ mild pitting, slight indentation, no visible swelling of the leg
 2+ moderate pitting, indentations resolve rapidly
 3+ deep pitting, indentation remains for a brief time, leg appears swollen
 4+ very deep pitting, indentation remains, leg is very swollen
This scale can be subjective but can be used for evaluation and documentation.
Evaluate turgor by pinching a large fold of skin on the anterior chest wall, just below the clavicle. The
skin should promptly return to the original state when released, an indication of good turgor. Slow
return of the skin to the original state is indicative of dehydration.
Cherry or senile angiomas are tiny bright red dots that are usually found on the trunk in adults age 30
years and older. These angiomas tend to increase in size and quantity as the patient ages but are not
significant, except for cosmetic purposes.
Note any ecchymotic patterns, keeping in mind that some bruising may be present due to daily
activities. Venous varicosities are not a normal finding and should be documented.
Tattoos, including cosmetic tattoos, should be documented.
Document the following information about any lesions that may be present:
Color, elevation, pattern or shape, size in centimeters, location and distribution on the body, and any
exudate or drainage to include color and odor.
Palpate the lesion(s) while wearing gloves. You may evaluate depth by rolling the lesion between your
thumb and forefinger. Gently scrape the lesion to assess for flaking, scaling, drainage, bleeding, and the
base of the lesion. Is the surrounding area erythematous or warm? Does the lesion blanch to pressure?
A magnifier glass and good light source should be used for closer inspection of lesions. A Wood’s light
may be helpful to evaluate fluorescing lesions. If scrapings are taken, a potassium hydroxide (KOH)
preparation can be used to diagnose fungal infections. A scraping is best obtained by using a sharp
sterile blade to scrape lightly across the edge of a lesion, taking care not to “dig in” while gently
scraping. Place the scrapings on a clean slide and add a drop of 10 to 20 percent KOH and send the slide
to the lab. The KOH solution will dissolve any nonfungal material that may be present, leaving the fungal
material for evaluation.
Hair
Inspect and palpate the hair color, length, texture, and distribution. Assess the scalp for any lesions,
trauma, erythema, or edema.
Nails
The nail surface should be flat or slightly curved, while the nail folds are smooth and rounded. No
discoloration, pitting, flaking, or splitting. The nail should be firmly attached to the nail bed. Capillary
refill to the nail bed should be brisk.
The Self-Skin Exam
Review the ABCDE rule for skin lesions with the patient. Then, discuss the self-skin exam he or she
should be conducting at home. The patient will need a full-length mirror and a small handheld mirror
and be in a well-lit room. The patient should undress completely, and then begin by examining the
hands (back and front), in between the fingers, and the forearms. The patient will face the mirror, bend
the elbows, and examine the posterior forearms. He or she should stand in front of the mirror and look
at the entire body, starting at the head and moving down to the feet.

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