🎨 Skin Color

Derived from three main sources:

• Melanin → brown pigment
• Carotene → yellow-orange pigment
• Underlying vascular bed → red-purple tones

📌 Skin color varies by relative proportion of these pigments and is modified by skin thickness and presence of edema.

👶 Developmental Competence

Children

• Epidermis thickens, darkens, becomes more lubricated
• Hair growth accelerates

Adolescents

• Increased apocrine sweat gland activity → body odor
• Increased sebaceous activity → acne
• Increased subcutaneous fat deposits
• Development of secondary sex characteristics
• Comedones: are small, non-inflammatory skin lesions that form when the pores become clogged with dead skin cells (keratin) and oil (sebum)

Close comedones:

Open comedones

👩‍🍼 Developmental Competence: The Pregnant Woman

• Metabolism increases → more secretion from sweat and sebaceous glands to help dissipate heat.
• Skin color changes are expected due to hormonal shifts (e.g., linea nigra, chloasma).

• Fat deposits are laid down → serve as maternal reserves for breastfeeding.
• Vascular spiders.

• Striae

👵 Developmental Competence: The Aging Adult

• Elasticity → decreases; skin loses turgor, causing sagging and folds.
• Sweat & sebaceous glands → decrease in number and function → dry skin.
• Senile purpura → dark red/purple discoloration from capillary fragility.
• Skin breakdown → higher risk due to slower cell replacement and delayed wound healing.
• Hair matrix → decreased melanocyte function → gray, fine hair.

📌 Quick Summary

• Skin = largest organ; 3 layers (epidermis, dermis, subcutaneous).
• Color = melanin, carotene, vascular bed.
• Hair = vellus + terminal; glands = sebaceous, eccrine, apocrine.
• Nails = keratin plates.
• Functions = protection, sensory, temp regulation, wound repair, vitamin D production.
• Development:
• Newborn → lanugo, vernix, milia.
• Children → thicker skin, more hair.
• Adolescents → sweat, fat deposits, secondary sex traits.
• Pregnancy: ↑ metabolism, ↑ sweat/oil, hormone-related skin changes, fat storage for nursing.
• Aging: ↓ elasticity, ↓ sweat/oil, senile purpura, delayed healing, gray/fine hair.

🌞 Skin Cancer & Environmental Risks

• The most important environmental risk factor for skin cancer is ultraviolet (UV) radiation, both from the sun and indoor tanning sources.
• Increased number of sunburns across a lifetime → increases risk for melanoma.
• Certain skin presentations are more common in specific ethnic groups (e.g., keloids in African Americans, pallor/jaundice more visible in lighter skin tones).

📝 Subjective Data: Health History Questions

Ask patients about:

• Past history of skin disease (allergies, hives, psoriasis, eczema).
• Pigmentation changes.
• Changes in moles (size, color).
• Excessive dryness or moisture.
• Pruritus (itching).
• Excessive bruising.
• Rash or lesions.
• Current medications.
• Hair loss or scalp changes.
• Nail changes.
• Environmental/occupational hazards (chemicals, sun exposure).
• Patient-centered care → routine hygiene, skin protection.

👦 Adolescents

• Ask about skin problems: pimples, blackheads, acne.

👵 Aging Adults

• Notable changes in skin in recent years.
• Delay in wound healing.
• Changes in feet: toenails, bunions, shoe fit.
• History of falls, bruising, trauma.
• Presence of diabetes or peripheral vascular disease, which may impair skin health and healing.

📌 Quick Summary

• UV radiation = top risk factor for skin cancer.
• Subjective questions focus on: skin diseases, pigment/mole changes, rashes, meds, hair, nails, hazards.
• Children: ask about rashes, diaper rash, birthmarks, sun protection.
• Adolescents: acne/skin problems.
• Older adults: wound healing, foot care, falls, diabetes/PVD.

🔍 Objective Data: Skin, Hair, and Nails

🧾 Preparation & Equipment

• Preparation: consciously attend to skin characteristics; danger = omission.
• Equipment: strong direct lighting, gloves, penlight, small ruler (cm).
• Special procedures:
• Wood’s light (UV filter)
• Magnifying glass
• Lab tests (KOH prep, glass slide for fungal infections)

👀 Physical Examination

Complete Physical Exam

• Integrate skin assessment throughout full exam.
• Scrutinize outer skin surface first, then underlying structures.
• Separate intertriginous areas (skin folds: under breasts, abdomen, groin).
• Always inspect feet, toenails, between toes.

Regional Exam

• When a patient presents with a skin complaint, focus exam on skin as one entity.
• Consider overall patterns and distribution.

🖐 Inspection & Palpation: Skin

1. Color

• Look at general pigmentation: freckles, moles, birthmarks.
• Watch for widespread color changes:
• Pallor (pale)
• Erythema (red)
• Cyanosis (blue)
• Jaundice (yellow)
• Determine if change is transient or pathologic.

2. Temperature

• Use backs of hands for palpation.
• Normal = warm, equal bilaterally.
• Hands/feet may be cooler in cold environments.
• Abnormal: hypothermia, hyperthermia.

3. Moisture

• Diaphoresis (excessive sweating).
• Dehydration (dry mucous membranes, poor skin moisture).

4. Texture

• Normal = smooth, firm, even surface.

5. Thickness

• Normal = thin and even; look for callus as localized thickening.

6. Edema

• Assess for swelling from fluid in interstitial space.

7. Mobility & Turgor

• Pinch skin fold → should be mobile and return quickly.
• Poor turgor = dehydration, aging.

8. Vascularity / Bruising

• Look for bruises, tattoos, or vascular patterns.
• Senile purpura common in aging.

9. Lesions (if present, describe):

• Color
• Elevation (flat, raised, pedunculated)
• Pattern/shape (linear, annular, grouped)
• Size (measure in cm)
• Location/distribution
• Exudate (color, odor)
• Special test: Wood’s light for fluorescing fungal lesions.

💇 Inspection & Palpation: Hair

• Color → due to melanin production.
• Texture → fine, thick, curly, straight; influenced by products and ethnicity.
• Distribution → Tanner staging for puberty/hair patterns.
• Lesions → examine scalp by parting hair in sections.

💅 Inspection & Palpation: Nails

• Shape & Contour → Profile sign; normal nail base angle = ~160°.
• Consistency → smooth, uniform, not brittle or splitting.
• Color → translucent nail plate, pink nail bed; note ethnic variations.
• Capillary Refill → press to blanch and release; color should return in <2 seconds (indicates peripheral perfusion).

📌 Quick Summary

• Skin: check color, temp, moisture, texture, thickness, edema, turgor, vascularity, lesions.
• Hair: assess color, texture, distribution, scalp lesions.
• Nails: assess shape/contour, consistency, color, cap refill.
• Use Wood’s light & KOH prep for suspected fungal or fluorescing lesions.

👆 Profile Sign & Clubbing

🔹 Profile Sign

• To assess the nail base, view the index finger from the side (profile view).
• Normal → nail base angle ≈ 160°.

🔹 Clubbing

• Definition: Abnormal nail base angle >180°, with spongy nail bed and bulbous fingertip.
• Cause: Chronic oxygen deprivation → increased connective tissue growth.

Common Associations

• Chronic hypoxemia → COPD, emphysema, chronic bronchitis.
• Cardiac conditions → congenital cyanotic heart disease.
• Other causes → lung cancer, pulmonary fibrosis, inflammatory bowel disease, cirrhosis.

🧴 ABCDEF Skin Assessment

🔹 Purpose

• Used to teach self-examination for suspicious skin lesions.
• Helps detect early signs of melanoma and other skin cancers.

🔠 ABCDEF Rule

• A – Asymmetry → one half of mole/lesion does not match the other.
• B – Border → irregular, ragged, notched, or blurred edges.
• C – Color → variations within the same lesion (brown, black, red, white, blue).
• D – Diameter → greater than 6 mm (about the size of a pencil eraser).
• E – Elevation / Evolution → raised lesion, or change in size, shape, or color over time.
• F – Funny looking → the “ugly duckling” sign — a lesion that looks different from the patient’s other moles.

👵 Aging – Normal Skin Changes

• Skin color/presentations
• Senile lentigines → “liver spots,” flat brown macules.
• Keratoses → raised, thickened lesions; may be seborrheic (oily, stuck-on) or actinic (red, scaly, precancerous).
• Moisture
• Xerosis → dry skin due to decreased sebaceous activity.
• Texture
• Skin tags (acrochordons) → overgrowths of normal skin, often in folds.
• Thickness
• Thin parchment-like skin, fragile and easily torn.
• Mobility & Turgor
• Decreased due to loss of elasticity.
• Hair & Nails
• Decreased hair and nail growth.
• Nails become brittle.

🎨 Detecting Color Changes in Skin

Be aware of normal variations in light vs dark skin when assessing for:

• Pallor
• Cyanosis
• Erythema
• Jaundice
• Brown-tan discolorations

🩺 Skin, Hair, and Nails – Clinical Findings

🔹 Pressure Injuries (Pressure Ulcers / Decubitus Ulcers)

• Stages:
• Stage I → Non-blanchable erythema of intact skin.
• Stage II → Partial-thickness skin loss.
• Stage III → Full-thickness skin loss.
• Stage IV → Full-thickness skin/tissue loss (may expose muscle/bone).
• Other types:
• DTPI (Deep Tissue Pressure Injury)
• Pressure injury caused by medical devices

✅ Summary Checklist: Skin, Hair, and Nails

• Inspection
• Color & pigmentation
• Texture & distribution
• Shape, contour, consistency (nails/hair)
• Palpation
• Temperature & texture
• Edema, mobility, turgor
• Lesions
• Note shape, configuration, distribution
• Patient Education
• Teach self-examination (e.g., ABCDEF skin rule)
• Promote health & prevention

⚠️ Attention

I didn’t include most abnormalities present in the PowerPoint, since they may not be tested.