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Chapter

55Chapter

55● Assessment of

Integumentary Function

On completion of this chapter, the learner will be able to:1. Identify the structures and functions of the skin.2. Differentiate the composition and function of each skin layer:

epidermis, dermis, and subcutaneous tissue.3. Identify and describe primary and secondary skin lesions and their

pattern and distribution.4. Recognize common skin eruptions and manifestations associated

with systemic disease.5. Describe the normal aging process of the skin and skin changes

common to elderly patients.6. List appropriate questions that will help elicit information during

an assessment of the skin.7. Describe the components of physical assessment most useful when

examining the skin, hair, and nails.8. Discuss common skin tests and procedures used in diagnosing skin

and related disorders.

1638

LEARNING OBJECTIVES ●

Chapter 55 Assessment of Integumentary Function 1639

Skin disorders are encountered frequently in nursing practice.Skin-related disorders account for up to 10% of all ambulatorypatient visits in this country. Because the skin mirrors the generalcondition of the patient, many systemic conditions may be accom-panied by dermatologic manifestations (Fleischer et al., 2000).

The psychological stress of illness or various personal and fam-ily problems is commonly exhibited outwardly as dermatologicproblems. Any hospitalized patient may suddenly develop itch-ing and a rash from the treatment regimen. In certain systemicconditions, such as hepatitis and some cancers, dermatologicmanifestations may be the first sign of the disorder.

Anatomic and Physiologic OverviewThe largest organ system of the body, the skin is indispensable forhuman life. Skin forms a barrier between the internal organs andthe external environment and participates in many vital body func-tions. The skin is contiguous with the mucous membrane at the ex-ternal openings of the digestive, respiratory, and urogenital systems.Because skin disorders are readily visible, dermatologic complaintsare commonly the primary reason for a patient to seek health care.

ANATOMY OF THE SKIN, HAIR, NAILS,AND GLANDS OF THE SKINThe skin is composed of three layers: epidermis, dermis, and sub-cutaneous tissue (Fig. 55-1). The epidermis is an outermost layerof stratified epithelial cells and composed predominantly of kera-tinocytes. It ranges in thickness from about 0.1 mm on the eye-lids to about 1 mm on the palms of the hands and soles of thefeet. Four distinct layers compose the epidermis, from innermostto outermost: stratum germinativum, stratum granulosum, stra-tum lucidum, and stratum corneum. Each layer becomes moredifferentiated (ie, mature and with more specific functions) as itrises from the basal stratum germinativum layer to the outermoststratum corneum layer.

EpidermisThe epidermis, which is contiguous with the mucous membranesand the lining of the ear canals, consists of live, continuously di-viding cells covered on the surface by dead cells that were origi-

nally deeper in the dermis but were pushed upward by the newlydeveloping, more differentiated cells underneath. This externallayer is almost completely replaced every 3 to 4 weeks. The deadcells contain large amounts of keratin, an insoluble, fibrous pro-tein that forms the outer barrier of the skin and has the capacityto repel pathogens and prevent excessive fluid loss from the body.Keratin is the principal hardening ingredient of the hair and nails.

Melanocytes are the special cells of the epidermis that are pri-marily involved in producing the pigment melanin, which col-ors the skin and hair. The more melanin in the tissue, the darkeris the color. Most of the skin of dark-skinned people and thedarker areas of the skin on light-skinned people (eg, the nipple)contain larger amounts of this pigment. Normal skin color de-pends on race and varies from pale; almost ivory, to deep brown,almost pure black. Systemic disease affects skin color as well. Forexample, the skin appears bluish when there is insufficient oxy-genation of the blood, yellow-green in people with jaundice, orred or flushed when there is inflammation or fever (Table 55-1).

Production of melanin is controlled by a hormone secretedfrom the hypothalamus of the brain called melanocyte-stimulatinghormone. It is believed that melanin can absorb ultraviolet lightin sunlight.

Two other cells are common to the epidermis: Merkel andLangerhans cells. Merkel cells are receptors that transmit stimulito the axon through a chemical synapse. Langerhans cells are be-lieved to play a significant role in cutaneous immune system re-actions. These accessory cells of the afferent immune systemprocess invading antigens and transport the antigens to the lymphsystem to activate the T lymphocytes.

The epidermis is modified in different areas of the body. It isthickest over the palms of the hands and soles of the feet and con-tains increased amounts of keratin. The thickness of the epider-mis can increase with use and can result in calluses forming onthe hands or corns forming on the feet.

The junction of the epidermis and dermis is an area of manyundulations and furrows called rete ridges. This junction an-chors the epidermis to the dermis and permits the free exchangeof essential nutrients between the two layers. This interlockingbetween the dermis and epidermis produces ripples on the sur-face of the skin. On the fingertips, these ripples are called finger-prints. They are a person’s most individual characteristic, andthey rarely change.

Glossaryalopecia: loss of hair from any causeanagen phase: active phase of hair growthdermatosis: any abnormal skin conditionerythema: redness of the skin caused by con-

gestion of the capillarieshirsutism: the condition of having excessive

hair growthhyperpigmentation: increase in the melanin

of the skin, resulting in an increase in pig-mentation

hypopigmentation: decrease in the melaninof the skin, resulting in a loss of pigmen-tation

keratin: an insoluble, fibrous protein thatforms the outer layer of skin

lichenification: leathery thickening of theskin

Merkel cells: cells of the epidermis that playa role in transmission of sensory messages

melanin: the substance responsible for col-oration of the skin

melanocytes: cells of the skin that producemelanin

petechiae: pinpoint red spots that appear onthe skin as a result of blood leakage intothe skin

rete ridges: undulations and furrows thatappear at the dermis–epidermis junctionand are responsible for cementing to-gether the two layers

sebaceous glands: glands that exist withinthe epidermis and secrete sebum to keepthe skin soft and pliable

sebum: fatty secretion of the sebaceousglands

striae: bandlike streaks on the skin, distin-guished by color, texture, depression, orelevation from the tissue in which they arefound; usually purplish or white

telangiectases: red marks on the skin causedby distention of the superficial bloodvessels

vitiligo: a localized or widespread conditioncharacterized by destruction of themelanocytes in circumscribed areas of theskin, resulting in white patches

Wood’s light: a blue light used for diagnos-ing skin conditions

1640 Unit 12 INTEGUMENTARY FUNCTION

DermisThe dermis makes up the largest portion of the skin, providingstrength and structure. It is composed of two layers: papillary andreticular. The papillary dermis lies directly beneath the epidermisand is composed primarily of fibroblast cells capable of produc-ing one form of collagen, a component of connective tissue. Thereticular layer lies beneath the papillary layer and also producescollagen and elastic bundles. The dermis is also made up of bloodand lymph vessels, nerves, sweat and sebaceous glands, and hairroots. The dermis is often referred to as the “true skin.”

Subcutaneous TissueThe subcutaneous tissue, or hypodermis, is the innermost layerof the skin. It is primarily adipose tissue, which provides a cush-ion between the skin layers, muscles, and bones. It promotes skinmobility, molds body contours, and insulates the body. Fat is de-posited and distributed according to the person’s gender and inpart accounts for the difference in body shape between men andwomen. Overeating results in increased deposition of fat beneaththe skin. The subcutaneous tissues and amount of fat depositedare important factors in body temperature regulation.

HairAn outgrowth of the skin, hair is present over the entire body ex-cept for the palms and soles. The hair consists of a root formedin the dermis and a hair shaft that projects beyond the skin. Itgrows in a cavity called a hair follicle. Proliferation of cells in thebulb of the hair causes the hair to form (see Fig. 55-1).

Hair follicles undergo cycles of growth and rest. The rate ofgrowth varies; beard growth is the most rapid, followed by hair onthe scalp, axillae, thighs, and eyebrows. The growth or anagenphase may last up to 6 years for scalp hair, whereas the telogen orresting phase lasts for approximately 4 months. During telogen,hair sheds from the body. The hair follicle recycles into the grow-ing phase spontaneously, or it can be induced by plucking outhairs. Growing and resting hair can be found side by side on allparts of the body. About 90% of the 100,000 hair follicles on a

normal scalp are in the growing phase at any one time, and 50 to100 scalp hairs are shed each day.

There is a small bulge on the side of the hair follicle thathouses the stem cells that migrate down to the follicle root andbegin the cycle of reproducing the hair shaft. It was discoveredthat these bulges also contain the stem cells that migrate upward toreproduce skin (Jaworski & Gilliam, 1999). The location of thesecells on the side of the hair shaft rather than at the base is a fac-tor in hair loss. In conditions in which inflammation causes dam-age to the root of the hair, regrowth is possible. However, ifinflammation causes damage to the bulge on the side, stem cellsare destroyed and hair does not grow.

In certain locations on the body, hair growth is controlled bysex hormones. The most vivid example is the growth of hair onthe face (ie, beard and mustache), chest, and back, which is con-trolled by the male hormones known as androgens. Some womenwith higher levels of testosterone have hair in the areas generallythought of as masculine, such as the face, chest, and lower ab-domen. This is often a normal genetic variation; if it appearsalong with irregular menses and weight changes it may indicate ahormonal imbalance.

Hair in different parts of the body serves different functions.The hairs of the eyes (ie, eyebrows and lashes), nose, and earsfilter out dust, bugs, and airborne debris. The hair of the skinprovides thermal insulation in lower animals. This function is en-hanced during cold or fright by piloerection (ie, hairs standing onend), caused by contraction of the tiny erector muscles attachedto the hair follicle. The piloerector response that occurs in humansis probably vestigial (ie, rudimentary).

Hair color is supplied by various amounts of melanin withinthe hair shaft. Gray or white hair reflects the loss of pigment.Hair quantity and distribution can be affected by endocrineconditions. For example, Cushing’s syndrome causes hirsutism(ie, excessive hair growth, especially in women), and hypothyroid-ism (ie, underactive thyroid) causes changes in hair texture. Inmany cases, chemotherapy and radiation therapy cause hair thin-ning or weakening of the hair shaft, resulting in partial or com-plete alopecia (ie, hair loss) from the scalp and other parts ofthe body.

Hair shaft

Horny layerCellular layerSebaceousglandMuscle thaterects hair shaft

Sweat gland

Hair follicle

Vein

NerveArtery

Duct ofsweat gland

Epidermis

Dermis

Subcutaneoustissue

FIGURE 55-1 Anatomic structures of the skin. FromBickley, L. S., & Hoekelman, R. A. (2003). Bates’ guideto physical examination and history taking, 8th ed. Philadel-phia: Lippincott Williams & Wilkins.


NailsOn the dorsal surface of the fingers and toes, a hard, transparentplate of keratin, called the nail, overlies the skin. The nail growsfrom its root, which lies under a thin fold of skin called the cuti-cle. The nail protects the fingers and toes by preserving theirhighly developed sensory functions, such as for picking up smallobjects.

Nail growth is continuous throughout life, with an averagegrowth of 0.1 mm daily. Growth is faster in fingernails than toe-nails and tends to slow with aging. Complete renewal of a fin-gernail takes about 170 days, whereas toenail renewal takes 12 to18 months.

Glands of the SkinThere are two types of skin glands: sebaceous glands and sweatglands (see Fig. 55-1). The sebaceous glands are associated withhair follicles. The ducts of the sebaceous glands empty sebum (ie,oily secretion) onto the space between the hair follicle and thehair shaft. For each hair there is a sebaceous gland, the secretionsof which lubricate the hair and render the skin soft and pliable.

Sweat glands are found in the skin over most of the body sur-face. They are heavily concentrated in the palms of the hands andsoles of the feet. Only the glans penis, the margins of the lips, theexternal ear, and the nail bed are devoid of sweat glands. Sweatglands are subclassified into two categories: eccrine and apocrine.

The eccrine sweat glands are found in all areas of the skin.Their ducts open directly onto the skin surface. The thin, waterysecretion called sweat is produced in the basal coiled portion ofthe eccrine gland and is released into its narrow duct. Sweat iscomposed of predominantly water and contains about one half ofthe salt content of the blood plasma. Sweat is released from ec-crine glands in response to elevated ambient temperature and el-evated body temperature. The rate of sweat secretion is under thecontrol of the sympathetic nervous system. Excessive sweating ofthe palms and soles, axillae, forehead, and other areas may occurin response to pain and stress.

The apocrine sweat glands are larger, and unlike eccrine glands,their secretion contains parts of the secretory cells. They are lo-cated in the axillae, anal region, scrotum, and labia majora. Theirducts generally open onto hair follicles. The apocrine glands be-come active at puberty. In women, they enlarge and recede witheach menstrual cycle. Apocrine glands produce a milky sweat thatis sometimes broken down by bacteria to produce the characteris-tic underarm odor. Specialized apocrine glands called ceruminousglands are found in the external ear, where they produce cerumen(ie, wax).

FUNCTIONS OF THE SKINProtectionThe skin covering most of the body is no more than 1 mm thick,but it provides very effective protection against invasion by bac-teria and other foreign matter. The thickened skin of the palmsand soles protects against the effects of the constant trauma thatoccurs in these areas.

The epidermis is the outermost layer of the skin and is com-posed of several layers of keratinocytes that change character asthey migrate to the surface. The stratum corneum, the outer layer

of the epidermis, provides the most effective barrier to epidermalwater loss and penetration of environmental factors such as chem-icals, microbes, and insect bites.

Various lipids are synthesized in the stratum corneum and arethe basis for the barrier function of this layer. These are long-chain lipids that are better suited than phospholipids for water re-sistance. The presence of these lipids in the stratum corneumcreates a relatively impermeable barrier for water egress and forthe entry of toxins, microbes, and other substances that come incontact with the surface of the skin.

Some substances do penetrate the skin but meet resistance intrying to move through the channels between the cell layers of thestratum corneum. Microbes and fungi, which are part of thebody’s normal flora, cannot penetrate unless there is a break inthe skin barrier.

The dermis–epidermis junction is the basal layer, which iscomposed of collagen. The basal layer serves four functions. Itacts as a scaffold for tissue organization and a template for regen-eration; it provides selective permeability for filtration of serum;it is a physical barrier between different types of cells; and it ad-heres the epithelium to underlying cell layers.

SensationThe receptor endings of nerves in the skin allow the body to con-stantly monitor the conditions of the immediate environment.The primary functions of the receptors in the skin are to sensetemperature, pain, light touch, and pressure (or heavy touch).Different nerve endings respond to each of the different stimuli.Although the nerve endings are distributed over the entire body,they are more concentrated in some areas than in others. For ex-ample, the fingertips are more densely innervated than the skinon the back.

Fluid BalanceThe stratum corneum (ie, outermost layer of the epidermis) hasthe capacity to absorb water, thereby preventing an excessive lossof water and electrolytes from the internal body and retainingmoisture in the subcutaneous tissues. When skin is damaged, asoccurs with a severe burn, large quantities of fluids and electro-lytes may be lost rapidly, possibly leading to circulatory collapse,shock, and death.

The skin is not completely impermeable to water. Small amountsof water continuously evaporate from the skin surface. This evap-oration, called insensible perspiration, amounts to approximately600 mL daily in a normal adult. Insensible water loss varies withthe body and ambient temperature. In a person with a fever, theloss can increase. During immersion in water, the skin can accu-mulate water up to three or four times its normal weight, such asswelling of the skin that occurs after prolonged bathing.

Temperature RegulationThe body continuously produces heat as a result of the metabo-lism of food, which produces energy. This heat is dissipated pri-marily through the skin. Three major physical processes areinvolved in loss of heat from the body to the environment. Thefirst process, radiation, is the transfer of heat to another object of


lower temperature situated at a distance. The second process,conduction, is the transfer of heat from the body to a coolerobject in contact with it. Heat transferred by conduction to theair surrounding the body is removed by the third process, con-vection, which consists of movement of warm air molecules awayfrom the body.

Evaporation from the skin aids heat loss by conduction. Heatis conducted through the skin into water molecules on its surface,causing the water to evaporate. The water on the skin surface maybe from insensible perspiration, sweat, or the environment.

Normally, all of these mechanisms for heat loss are used.When the ambient temperature is very high, however, radiationand convection are ineffective, and evaporation becomes the onlymeans for heat loss.

Under normal conditions, metabolic heat production is bal-anced by heat loss, and the internal temperature of the body ismaintained constant at approximately 37°C (98.6°F). The rateof heat loss depends primarily on the surface temperature of theskin, which is a function of the skin blood flow. Under normalconditions, the total blood circulated through the skin is approx-imately 450 mL per minute, or 10 to 20 times the amount ofblood required to provide necessary metabolites and oxygen.Blood flow through these skin vessels is controlled primarily bythe sympathetic nervous system. Increased blood flow to the skinresults in more heat delivered to the skin and a greater rate of heatloss from the body. In contrast, decreased skin blood flow de-creases the skin temperature and helps conserve heat for the body.When the temperature of the body begins to fall, as occurs on acold day, the blood vessels of the skin constrict, thereby reducingheat loss from the body.

Sweating is another process by which the body can regulatethe rate of heat loss. Sweating does not occur until the core bodytemperature exceeds 37°C, regardless of skin temperature. In ex-tremely hot environments, the rate of sweat production may beas high as 1 L per hour. Under some circumstances (eg, emotionalstress), sweating may occur as a reflex and may be unrelated to theneed to lose heat from the body.

Vitamin ProductionSkin exposed to ultraviolet light can convert substances necessaryfor synthesizing vitamin D (cholecalciferol). Vitamin D is essen-tial for preventing rickets, a condition that causes bone deformi-ties and results from a deficiency of vitamin D, calcium, andphosphorus.

Immune Response FunctionResearch findings (Demis, 1998) indicate that several dermal cells(ie, Langerhans cells, interleukin-1–producing keratinocytes, andsubsets of T lymphocytes) and three varieties of human leukocyteantigen (ie, protein marker on white blood cells indicating thetype of cell) are important components of the immune system.Ongoing research is expected to more clearly define the role ofthese dermal cells in immune function.

Gerontologic Considerations

The skin undergoes many physiologic changes associated withnormal aging. A lifetime of excessive sun exposure, systemic dis-eases, poor nutrition, and certain medications (eg, antihista-mines, diuretics) can enhance the range of skin problems and the

rapidity with which they appear. The outcome is an increasingvulnerability to injury and to certain diseases. Skin problems arecommon among older people.

Before conducting a skin assessment, the nurse needs to beaware of significant changes that occur with aging. The majorchanges in the skin of older people include dryness, wrinkling,uneven pigmentation, and various proliferative lesions. Cellularchanges associated with aging include a thinning at the junctionof the dermis and epidermis. This results in fewer anchoring sitesbetween the two skin layers, so that even minor injury or stress tothe epidermis can cause it to shear away from the dermis. Thisphenomenon of aging may account for the increased vulnerabil-ity of aged skin to trauma. With increasing age, the epidermis anddermis thin and flatten, causing wrinkles, sags, and overlappingskin folds (Fig. 55-2).

Loss of the subcutaneous tissue substances of elastin, collagen,and subcutaneous fat diminishes the protection and cushioningof underlying tissues and organs, decreases muscle tone, and re-sults in the loss of the insulating properties of fat.

Cellular replacement slows as a result of aging. As the dermallayers thin, the skin becomes fragile and transparent. The bloodsupply to the skin also changes with age. Vessels, especially the cap-illary loops, decrease in number and size. These vascular changescontribute to the delayed wound healing commonly seen in theelderly patient. Sweat and sebaceous glands decrease in numberand functional capacity, leading to dry and scaly skin. Reducedhormonal levels of androgens are thought to contribute to declin-ing sebaceous gland function.

Hair growth gradually diminishes, especially over the lowerlegs and dorsum of the feet. Thinning is common in the scalp, ax-illa, and pubic areas. Other functions affected with normal aginginclude the barrier function of skin, sensory perception, and ther-moregulation.

Photoaging, or damage from excessive sun exposure, has detri-mental effects on the normal aging of skin. A lifetime of outdoorwork or outdoor activities (eg, construction work, lifeguarding,sunbathing) without prudent use of sunscreens can lead to pro-found wrinkling; increased loss of elasticity; mottled, pigmentedareas; cutaneous atrophy; and benign or malignant lesions.

Many skin lesions are part of normal aging. Recognizing theselesions enables the examiner to assist the patient to feel less anx-

FIGURE 55-2 Hands with wrinkling and overlapping folds common toaging skin.


ious about changes in skin. Chart 55-1 summarizes some skin le-sions that are expected to appear as the skin ages. These are normaland require no special attention unless the skin becomes infectedor irritated.

AssessmentHEALTH HISTORY AND CLINICAL MANIFESTATIONSWhen caring for patients with dermatologic disorders, the nurseobtains important information through the health history and di-rect observations. The nurse’s skill in physical assessment and anunderstanding of the anatomy and function of the skin can en-sure that deviations from normal are recognized, reported, anddocumented.

During the health history interview, the nurse asks about anyfamily and personal history of skin allergies, allergic reactions to

Benign Changes in Elderly Skin

• Cherry angiomas (bright red “moles”)• Diminished hair, especially on scalp and pubic area• Dyschromias (color variations)

Solar lentigo (liver spots)Melasma (dark discoloration of the skin)Lentigines (freckles)

• Neurodermatitis (itchy spots)• Seborrheic keratoses (crusty brown “stuck-on” patches)• Spider angiomas• Telangiectasias (red marks on skin caused by stretching of the

superficial blood vessels)• Wrinkles• Xerosis (dryness)• Xanthelasma (yellowish waxy deposits on upper and lower

eyelids)

Chart55-1

Chart55-1

Examples of integumentary conditions influenced by geneticfactors include the following:• Albinism• Eczema• Hypohidrotic ectodermal dysplasia• Incontinentia pigmenti• Neurofibromatosis type 1• Pseudoxanthoma elasticum• Psoriasis

NURSING ASSESSMENTSFAMILY HISTORY ASSESSMENT

• Assess for other closely related family members with integu-mentary impairment or abnormalities.

• Inquire about the nature and type of skin lesions and age atonset (eg, skin involvement with incontinentia pigmenti oc-curs in the first few weeks of life with blistering of the skin,whereas lesions of neurofibromatosis type 1 may appear inearly childhood through adulthood).

• Note gender of affected individuals (eg, mostly females withincontinentia pigmenti, mostly males with hypohidrotic ec-todermal dysplasia).

• Inquire about the presence of other clinical features, such asunusual hair, teeth, or nails; thrombocytopenia; recurrentinfections.

PHYSICAL ASSESSMENT

• Assess for related clinical features, such as sparse eyebrowsand eyelashes, abnormally shaped teeth, alopecia, nail abnor-malities (eg, hypohidrotic ectodermal dysplasia).

• Assess for related alterations in vision, such as nystagmus,strabismus; albinism; retinal abnormalities (eg, pseudo-

xanthoma elasticum); Lisch nodules and/or optic glioma(neurofibromatosis type 1).

MANAGEMENT ISSUES SPECIFIC TO GENETICS• Inquire whether DNA mutation or other genetic testing has

been performed on affected family members.• If indicated, refer for further genetic counseling and evalua-

tion so that family members can discuss inheritance, risk toother family members, availability of genetic testing, andgene-based interventions.

• Offer appropriate genetics information and resources.• Assess patient’s understanding of genetics information.• Provide support to families with newly diagnosed genetic-

related integumentary conditions.• Participate in management and coordination of care for pa-

tients with genetic conditions and for individuals predisposedto develop or pass on a genetic condition.

GENETICS RESOURCES FOR NURSES AND THEIR PATIENTS ON THE WEBGenetic Alliance—a directory of support groups for patients and

families with genetic conditions; http://www.geneticalliance.org

Gene Clinics—a listing of common genetic disorders with clini-cal summaries, genetic counseling and testing information;http://www.geneclinics.org

National Organization of Rare Disorders—a directory of supportgroups and information for patients and families with rare ge-netic disorders; http://www.rarediseases.org

Online Mendelian Inheritance in Man (OMIM)—a completelisting of inherited genetic conditions; http://www.ncbi.nlm.nih.gov/omim/stats/html

GENETICS IN NURSING PRACTICE—Integumentary Conditions


food, medications, chemicals, previous skin problems, and skincancer. The names of cosmetics, soaps, shampoos, and other per-sonal hygiene products are obtained if there have been any recentskin problems noticed with the use of these products. The healthhistory contains specific information about the onset, signs andsymptoms, location, and duration of any pain, itching, rash, orother discomfort experienced by the patient. The accompanying as-sessment chart lists selected questions useful in obtaining appropri-ate information (Chart 55-2).

PHYSICAL ASSESSMENTAssessment of the skin involves the entire skin area, including themucous membranes, scalp, hair, and nails. The skin is a reflectionof a person’s overall health, and alterations commonly correspondto disease in other organ systems. Inspection and palpation aretechniques commonly used in examining the skin. The room mustbe well lighted and warm. A penlight may be used to highlightlesions. The patient completely disrobes and is adequately draped.Gloves are worn during skin examination if rash or lesions are tobe palpated. However, it is important to avoid making the patientfeel as if he or she cannot be touched. Touching skin lesions in-dicates a level of acceptance of the patient.

Assessing General AppearanceThe general appearance of the skin is assessed by observing color,temperature, moisture or dryness, skin texture (rough or smooth),lesions, vascularity, mobility, and the condition of the hair andnails. Skin turgor, possible edema, and elasticity are assessed bypalpation.

Skin color varies from person to person and ranges from ivoryto deep brown to almost pure black. The skin of exposed portionsof the body, especially in sunny, warm climates, tends to be morepigmented than the rest of the body. The vasodilation that occurswith fever, sunburn, and inflammation produces a pink or reddishhue to the skin. Pallor is an absence of or a decrease in normal skincolor and vascularity and is best observed in the conjunctivae oraround the mouth.

The bluish hue of cyanosis indicates cellular hypoxia and iseasily observed in the extremities, nail beds, lips, and mucousmembranes. Jaundice, a yellowing of the skin, is directly relatedto elevations in serum bilirubin and is often first observed in thesclerae and mucous membranes (Fig. 55-3).

ErythemaErythema is redness of the skin caused by the congestion of cap-illaries. In light-skinned people, it is easily observed at any loca-tion where it appears. To determine possible inflammation, theskin is palpated for increased warmth and for smoothness (ie,edema) or hardness (ie, intracellular infiltration). Because darkskin tends to assume a purple-gray cast when an inflammatoryprocess is present, it may be difficult to detect erythema.

RashIn instances of pruritus (ie, itching), the patient should be askedto indicate which areas of the body are involved. The skin is thenstretched gently to decrease the reddish tone and make the rashstand out. Pointing a penlight laterally across the skin may ef-fectively highlight the rash. The differences in skin texture arethen assessed by running the tips of the fingers lightly over theskin. The borders of the rash may be palpable. The patient’smouth and ears are included in the examination. (Sometimesrubeola, or measles, causes a red cast to appear on the tip of theears.) The patient’s temperature is assessed, and the lymph nodesare palpated.

Chart 55-2 • ASSESSMENT

Patient History of Skin Disorders

Patient history relevant to skin disorders may be obtained by askingthe following questions:

When did you first notice this skin problem? (Also investigateduration and intensity.)

Has it occurred previously?Are there any other symptoms?What site was first affected?What did the rash or lesion look like when it first appeared?Where and how fast did it spread?Do you have any itching, burning, tingling, or crawling

sensations?Is there any loss of sensation?Is the problem worse at a particular time or season?How do you think it started?Do you have a history of hay fever, asthma, hives, eczema,

or allergies?Who in your family has skin problems or rashes?Did the eruptions appear after certain foods were eaten?

Which foods?When the problem occurred, had you recently consumed alcohol?What relation do you think there may be between a specific

event and the outbreak of the rash or lesion?What medications are you taking?What topical medication (ointment, cream, salve) have you put

on the lesion (including over-the-counter medications)?What skin products or cosmetics do you use?What is your occupation?What in your immediate environment (plants, animals,

chemicals, infections) might be precipitating this disorder?Is there anything new, or are there any changes in theenvironment?

Does anything touching your skin cause a rash?How has this affected you (or your life)?Is there anything else you wish to talk about in regard to this

disorder? FIGURE 55-3 Examples of skin color changes: the bluish tint of cyanosis(left) and the yellow hue of jaundice (right).

be described as primary or secondary. Primary lesions are the ini-tial lesions and are characteristic of the disease itself. Secondarylesions result from external causes, such as scratching, trauma, in-fections, or changes caused by wound healing. Depending on thestage of development, skin lesions are further categorized accord-ing to type and appearance (Chart 55-3).

A preliminary assessment of the eruption or lesion should helpto identify the type of dermatosis (ie, abnormal skin condition)and indicate whether the lesion is primary or secondary. At thesame time, the anatomic distribution of the eruption should be ob-served, because certain diseases affect certain sites of the body andare distributed in characteristic patterns and shapes (Figs. 55-4 and55-5). To determine the extent of the regional distribution,the left and right sides of the body should be compared while thecolor and shape of the lesions are assessed. After observation, thelesions are palpated to determine their texture, shape, and borderand to see if they are soft and filled with fluid or hard and fixedto the surrounding tissue.

A metric ruler is used to measure the size of the lesions so thatany further extension can be compared with this baseline mea-surement. The dermatosis is documented on the patient’s healthrecord; it should be described clearly and in detail, using preciseterminology.

After the characteristic distribution of the lesions has been de-termined, the following information should be obtained anddescribed clearly and in detail:

• Color of the lesion• Any redness, heat, pain, or swelling• Size and location of the involved area• Pattern of eruption (eg, macular, papular, scaling, oozing,

discrete, confluent)• Distribution of the lesion (eg, bilateral, symmetric, linear,

circular)

If acute open wounds or lesions are found on inspection of theskin, a comprehensive assessment should be made and docu-mented in the patient’s record. This assessment should addressseveral issues:

• Wound bed: Inspect for necrotic and granulation tissue,epithelium, exudate, color, and odor.

• Wound edges and margins: Observe for undermining (ie,extension of the wound under the surface skin), and evalu-ate for condition.

• Wound size: Measure in millimeters or centimeters, as ap-propriate, to determine diameter and depth of the woundand surrounding erythema.

• Surrounding skin: Assess for color, suppleness and mois-ture, irritation, and scaling.

Assessing Vascularity and HydrationAfter the color of the skin has been evaluated and lesions havebeen inspected, an assessment of vascular changes in the skin isperformed. A description of vascular changes includes location,distribution, color, size, and the presence of pulsations. Commonvascular changes include petechiae, ecchymoses, telangiectases(ie, red marks on the skin caused by stretching of the superficialblood vessels), angiomas, and venous stars.

Skin moisture, temperature, and texture are assessed primar-ily by palpation. The elasticity (ie, turgor) of the skin, which de-creases in normal aging, may be a factor in assessing the hydrationstatus of a patient.


CyanosisCyanosis is the bluish discoloration that results from a lack ofoxygen in the blood. It appears with shock or with respiratory orcirculatory compromise. In people with light skin, cyanosis man-ifests as a bluish hue to the lips, fingertips, and nail beds. Otherindications of decreased tissue perfusion include cold, clammyskin; a rapid, thready pulse; and rapid, shallow respirations. Theconjunctivae of the eyelids are examined for pallor and petechiae(ie, pinpoint red spots that appear on the skin as a result of bloodleakage into the skin).

In a person with dark skin, the skin usually assumes a grayishcast. To detect cyanosis, the areas around the mouth and lips andover the cheekbones and earlobes should be observed.

Color ChangesAlmost every process that occurs on the skin causes some colorchange. For example, hypopigmentation (ie, decrease in themelanin of the skin, resulting in a loss of pigmentation) may becaused by a fungal infection, eczema, or vitiligo (ie, conditioncharacterized by destruction of the melanocytes in circum-scribed areas of the skin, resulting in white patches). Hyper-pigmentation (ie, increase in the melanin of the skin, resultingin increased pigmentation) may occur after disease or injury tothe skin (ie, postinflammatory), after sun injury, or as a resultof aging.

Changes in skin color in people with dark skin are more no-ticeable and may cause more concern because the discoloration ismore readily visible. Some variation in skin pigment levels is con-sidered normal. Examples include the pigmented crease across thebridge of the nose, pigmented streaks in the nails, and pigmentedspots on the sclera of the eye. Many variations of color are genet-ically determined.

ASSESSING PATIENTS WITH DARK SKINThe color gradations that occur in people with dark skin arelargely determined by genetic transmission; they may be describedas light, medium, or dark. In people with dark skin, melanin isproduced at a faster rate and in larger quantities than in peoplewith light skin. Healthy dark skin has a reddish base or under-tone. The buccal mucosa, tongue, lips, and nails normally arepink. The degree of pigmentation of the patient’s skin may affectthe appearance of a lesion. Lesions may be black, purple, or grayinstead of the tan or red seen in patients with light skin. Dark pig-ment responds with discoloration after injury or inflammation,and patients with dark skin more often experience post-inflammatory hyperpigmentation than those with lighter skin.The hyperpigmentation eventually fades but may require monthsto a year to do so.

In general, people with dark skin suffer the same skin condi-tions as those with light skin. They are less likely to have skin can-cer but more likely to have keloid or scar formation and disordersresulting from occlusion or blockage of hair follicles.

Table 55-2 provides an overview of color changes in light-skinned and dark-skinned people, and the following section pro-vides specific guidelines for assessing dark and light skin.

ASSESSING SKIN LESIONSSkin lesions are the most prominent characteristics of dermato-logic conditions. They vary in size, shape, and cause and are clas-sified according to their appearance and origin. Skin lesions can


Assessing the Nails and HairA brief inspection of the nails includes observation of configura-tion, color, and consistency. Many alterations in the nail or nailbed reflect local or systemic abnormalities in progress or resultingfrom past events (Fig. 55-6). Transverse depressions known asBeau’s lines in the nails may reflect retarded growth of the nailmatrix because of severe illness or, more commonly, local trauma.Ridging, hypertrophy, and other changes may also be visible with

local trauma. Paronychia, an inflammation of the skin around thenail, is usually accompanied by tenderness and erythema. Theangle between the normal nail and its base is 160 degrees. Whenpalpated, the nail base is usually firm. Clubbing is manifested bya straightening of the normal angle (180 degrees or greater) andsoftening of the nail base. The softened area feels spongelike whenpalpated.

Table 55-2 • Color Changes in Light and Dark Skin

ETIOLOGY LIGHT SKIN DARK SKIN

PallorAnemia—decreased hematocritShock—decreased perfusion, vasoconstriction

Local arterial insufficiency

Albinism—total absence of pigment melanin

Vitiligo—a condition characterized by de-struction of the melanocytes in circum-scribed areas of the skin (may be localizedor widespread)

CyanosisIncreased amount of unoxygenated

hemoglobin:

Central—chronic heart and lung diseasecause arterial desaturation

Peripheral—exposure to cold, anxiety

ErythemaHyperemia—increased blood flow through

engorged arterial vessels, as in inflamma-tion, fever, alcohol intake, blushing

Polycythemia—increased red blood cells,capillary stasis

Carbon monoxide poisoning

Venous stasis—decreased blood flow fromarea, engorged venules

JaundiceIncreased serum bilirubin concentration

(>2–3 mg/100 mL) due to liver dysfunc-tion or hemolysis, as after severe burns orsome infections

Carotenemia—increased level of serumcarotene from ingestion of large amountsof carotene-rich foods

Uremia—renal failure causes retainedurochrome pigments in the blood

Brown-TanAddison’s disease—cortisol deficiency stimu-

lates increased melanin production

Café-au-lait spots—caused by increasedmelanin pigment in basal cell layer

Generalized pallor

Marked localized pallor (lower extremities,especially when elevated)

Whitish pink

Patchy, milky white spots, often symmetricbilaterally

Dusky blue

Nail beds dusky

Red, bright pink

Ruddy blue in face, oral mucosa, conjunctivae,hands and feet

Bright, cherry red in face and upper torso

Dusky rubor of dependent extremities (a prelude to necrosis with pressure ulcer)

Yellow first in sclerae, hard palate, andmucous membranes; then over skin

Yellow-orange tinge in forehead, palms andsoles, and nasolabial folds, but no yellow-ing in sclerae or mucous membranes

Orange-green or gray overlying pallor ofanemia; may also have ecchymoses andpurpura

Bronzed appearance, an “external tan”; mostapparent around nipples, perineum, geni-talia, and pressure points (inner thighs,buttocks, elbows, axillae)

Tan to light brown, irregularly shaped, oval patch with well-defined borders oftennot visible in the very dark skinned person

Brown skin appears yellow-brown, dull; blackskin appears ashen gray, dull. (Observe areaswith least pigmentation: conjunctivae,mucous membranes.)

Ashen gray, dull; cool to palpation

Tan, cream, white

Same

Dark but dull, lifeless; only severe cyanosis isapparent in skin. (Observe conjunctivae,oral mucosa, nail beds.)

Purplish tinge, but difficult to see. (Palpatefor increased warmth with inflammation,taut skin, and hardening of deep tissues.)

Well concealed by pigment. (Observe forredness in lips.)

Cherry red nail beds, lips, and oral mucosa

Easily masked. (Use palpation to identifywarmth or edema.)

Check sclerae for yellow near limbus; do notmistake normal yellowish fatty deposits inthe periphery under eyelids for jaundice.(Jaundice is best noted at junction of hardand soft palate, on palms.)

Yellow-orange tinge in palms and soles

Easily masked. (Rely on laboratory and clini-cal findings.)

Easily masked. (Rely on laboratory and clini-cal findings.)

(text continues on page 1650)


Plaque

Papule

VesicleBulla

Macule, PatchFlat, nonpalpable skin color change (color may be brown, white, tan,

purple, red)• Macule: <1 cm, circumscribed border• Patch: >1 cm, may have irregular border

Examples:Freckles, flat moles, petechia, rubella, vitiligo, port wine stains,

ecchymosis

Papule, PlaqueElevated, palpable, solid massCircumscribed borderPlaque may be coalesced papules with flat top• Papule: <0.5 cm• Plaque: >0.5 cm

Examples:Papules: Elevated nevi, warts, lichen planusPlaques: Psoriasis, actinic keratosis

Nodule, TumorElevated, palpable, solid massExtends deeper into the dermis than a papule• Nodule: 0.5–2 cm; circumscribed• Tumor: >1–2 cm; tumors do not always have sharp borders

Examples:Nodules: Lipoma, squamous cell carcinoma, poorly absorbed

injection, dermatofibromaTumors: Larger lipoma, carcinoma

Primary and Secondary Skin Lesions

PRIMARY SKIN LESIONSPrimary skin lesions are original lesions arising from previously normal skin. Secondary lesions can originate fromprimary lesions and are the progression of the primary disease to a different appearance.

Chart55-3

Chart55-3

Vesicle, BullaCircumscribed, elevated, palpable mass containing serous fluid• Vesicle: <0.5 cm• Bulla: >0.5 cm

Examples:Vesicles: Herpes simplex/zoster, chickenpox, poison ivy,

second-degree burn (blister)Bulla: Pemphigus, contact dermatitis, large burn blisters, poison ivy,

bullous impetigo

Wheal• Elevated mass with transient borders• Often irregular• Size and color vary• Caused by movement of serous fluid into the dermis• Does not contain free fluid in a cavity (as, for example, a vesicle

does)

Examples:Urticaria (hives), insect bites

Pustule• Pus-filled vesicle or bulla

Examples:Acne, impetigo, furuncles, carbuncles

Cyst• Encapsulated fluid-filled or semisolid mass• In the subcutaneous tissue or dermis

Examples:Sebaceous cyst, epidermoid cysts

(continued)

Patch

Macule

Tumor

Wheal

Pustule

Cyst


Primary and Secondary Skin Lesions (Continued)Chart55-3

Chart55-3

SECONDARY SKIN LESIONSSecondary skin lesions result from changes in primary lesions.

Erosion• Loss of superficial epidermis• Does not extend to dermis• Depressed, moist area

Examples:Ruptured vesicles, scratch marks

Ulcer• Skin loss extending past epidermis• Necrotic tissue loss• Bleeding and scarring possible

Examples:Stasis ulcer of venous insufficiency, pressure ulcer

Fissure• Linear crack in the skin• May extend to dermis

Examples:Chapped lips or hands, athlete’s foot

Scales• Flakes secondary to desquamated,

dead epithelium• Flakes may adhere to skin surface• Color varies (silvery, white)• Texture varies (thick, fine)

Examples:Dandruff, psoriasis, dry skin, pityriasis rosea

Crust• Dried residue of serum, blood, or pus on

skin surface• Large, adherent crust is a scab

Examples:Residue left after vesicle rupture: impetigo, herpes, eczema

Scar (Cicatrix)• Skin mark left after healing of a wound

or lesion• Represents replacement by connective

tissue of the injured tissue• Young scars: red or purple• Mature scars: white or glistening

Examples:Healed wound or surgical incision

Keloid• Hypertrophied scar tissue• Secondary to excessive collagen

formation during healing• Elevated, irregular, red• Greater incidence among African Americans

Example:Keloid of ear piercing or surgical incision

Atrophy• Thin, dry, transparent appearance

of epidermis• Loss of surface markings• Secondary to loss of collagen and elastin• Underlying vessels may be visible

Examples:Aged skin, arterial insufficiency

Lichenification• Thickening and roughening of the skin• Accentuated skin markings• May be secondary to repeated rubbing,

irritation, scratching

Example:Contact dermatitis

Erosion

Ulcer

Fissure

Scales

Crust

(continued)

Scar

Keloid

Atrophy

Lichenification


The hair assessment is carried out by inspecting and palpating.Gloves are worn, and the examination room should be well lighted.Separating the hair so that the condition of the skin underneathcan be easily seen, the nurse assesses color, texture, and distribu-tion. Any abnormal lesions, evidence of itching, inflammation,scaling, or signs of infestation (ie, lice or mites) are documented.

COLOR AND TEXTURENatural hair color ranges from white to black. Hair color beginsto gray with age, initially appearing during the third decade of life,when the loss of melanin begins to become apparent. However, itis not unusual for the hair of younger people to turn gray as a re-sult of hereditary traits. The person with albinism (ie, partial orcomplete absence of pigmentation) has a genetic predisposition towhite hair from birth. The natural state of the hair can be alteredby using hair dyes, bleaches, and curling or relaxing products. Thetypes of products used are identified during the assessment.

The texture of scalp hair ranges from fine to coarse, silky tobrittle, oily to dry, and shiny to dull, and hair can be straight,curly, or kinky. Dry, brittle hair may result from overuse of hairdyes, hair dryers, and curling irons or from endocrine disorders,

such as thyroid dysfunction. Oily hair is usually caused by in-creased secretion from the sebaceous glands close to the scalp. Ifthe patient reports a recent change in hair texture, the underlyingreason is pursued; the alteration may arise simply from the over-use of commercial hair products or from changing to a newshampoo.

DISTRIBUTIONBody hair distribution varies with location. Hair over most of thebody is fine, except in the axillae and pubic areas, where it iscoarse. Pubic hair, which develops at puberty, forms a diamondshape extending up to the umbilicus in boys and men. Femalepubic hair resembles an inverted triangle. If the pattern found ismore characteristic of the opposite gender, it may indicate an en-docrine problem and further investigation is in order. Racial dif-ferences in hair are expected, such as straight hair in Asians andcurly, coarser hair in people of African descent.

Men tend to have more body and facial hair than women.Loss of hair, or alopecia, can occur over the entire body or beconfined to a specific area. Scalp hair loss may be localized topatchy areas or may range from generalized thinning to total

Primary and Secondary Skin Lesions (Continued)Chart55-3

Chart55-3

VASCULAR SKIN LESIONS

Petechia (pl. petechiae)• Round red or purple macule• Small: 1–2 mm• Secondary to blood extravasation• Associated with bleeding tendencies or

emboli to skin

Ecchymosis (pl. ecchymoses)• Round or irregular macular lesion• Larger than petechia• Color varies and changes: black, yellow,

and green hues• Secondary to blood extravasation• Associated with trauma, bleeding tendencies

Cherry Angioma• Papular and round• Red or purple• Noted on trunk, extremities• May blanch with pressure• Normal age-related skin alteration• Usually not clinically significant

Spider Angioma• Red, arteriole lesion• Central body with radiating branches• Noted on face, neck, arms, trunk• Rare below the waist• May blanch with pressure• Associated with liver disease, pregnancy, vitamin B deficiency

Telangiectasia (Venous Star)• Shape varies: spider-like or linear• Color bluish or red• Does not blanch when pressure is applied• Noted on legs, anterior chest• Secondary to superficial dilation of venous vessels and capillaries• Associated with increased venous pressure states (varicosities)

Ecchymoses

Cherry angioma

Spider angioma

Telangiectasia

Petechiae


baldness. When assessing scalp hair loss, it is important to in-vestigate the underlying cause with the patient. Patchy hair lossmay be from habitual hair pulling or twisting; from excessivetraction on the hair (eg, braiding too tightly); excessive use ofdyes, straighteners, and oils; chemotherapeutic agents (eg, doxo-rubicin, cyclophosphamide); fungal infection; or moles or lesionson the scalp. Regrowth may be erratic, and distribution may neverattain the previous thickness.

HAIR LOSSThe most common cause of hair loss is male pattern baldness,which affects more than one half of the male population and isbelieved to be related to heredity, aging, and androgen (malehormone) levels. Androgen is necessary for male pattern bald-ness to develop. The pattern of hair loss begins with recedingof the hairline in the frontal-temporal area and progresses togradual thinning and complete loss of hair over the top of thescalp and crown. Figure 55-7 illustrates the typical male patternhair loss.

Early clubbing Late clubbing

Pitting Paronychia

180° >180°

Beau's lines Spoon nails

FIGURE 55-6 Common nail disorders. From Weber, J. W., & Kelley, J.(2003). Health assessment in nursing (2nd ed.). Philadelphia: LippincottWilliams and Wilkins.

FIGURE 55-5 Skin lesion configurations. (A) Linear (in a line). (B) An-nular and arciform (circular or arcing). (C) Zosteriform (linear along anerve route). (D) Grouped (clustered). (E) Discrete (separate and distinct).(F) Confluent (merged). From Weber, J. W., & Kelley, J. (2003). Healthassessment in nursing (2nd ed.). Philadelphia: Lippincott Williams andWilkins.

FIGURE 55-4 Anatomic distribution of common skin disorders. (A) Con-tact dermatitis (shoes). (B) Contact dermatitis (cosmetics, perfumes, ear-rings). (C) Seborrheic dermatitis. (D) Acne. (E) Scabies. (F) Herpes zoster(shingles).

A B

C D

E F

A B C

D E F


OTHER CHANGESMale pattern hair distribution may be seen in some women at thetime of menopause, when the hormone estrogen is no longer pro-duced by the ovaries. In women with hirsutism, excessive hairmay grow on the face, chest, shoulders, and pubic area. Whenmenopause is ruled out as the underlying cause, hormonal ab-normalities related to pituitary or adrenal dysfunction must beinvestigated.

Because patients with skin conditions may be viewed nega-tively by others, these patients may become distraught and avoidinteraction with people. Skin conditions can lead to disfigure-ment, isolation, job loss, and economic hardship.

Some conditions may subject the patient to a protracted illness,leading to feelings of depression, frustration, self-consciousness,poor self-image, and rejection. Itching and skin irritation, fea-tures of many skin diseases, may be a constant annoyance. Theresults of these discomforts may be loss of sleep, anxiety, and de-pression, all of which reinforce the general distress and fatiguethat frequently accompany skin disorders.

For patients suffering such physical and psychological dis-comforts, the nurse needs to provide understanding, explanationsof the problem, appropriate instructions related to treatment,nursing support, patience, and encouragement. It takes time tohelp patients gain insight into their problems and resolve theirdifficulties. It is imperative to overcome any aversion that may befelt when caring for patients with unattractive skin disorders. Thenurse should show no sign of hesitancy when approaching pa-tients with skin disorders. Such hesitancy only reinforces the psy-chological trauma of the disorder.

Diagnostic EvaluationIn addition to obtaining the patient’s history, the examiner in-spects the primary and secondary lesions and their configurationand distribution. Certain diagnostic procedures may also be usedto help identify skin conditions.

SKIN BIOPSYPerformed to obtain tissue for microscopic examination, a skinbiopsy may be obtained by scalpel excision or by a skin punch in-strument that removes a small core of tissue. Biopsies are per-

formed on skin nodules, plaques, blisters, and other lesions torule out malignancy and to establish an exact diagnosis.

IMMUNOFLUORESCENCEDesigned to identify the site of an immune reaction, immuno-fluorescence testing combines an antigen or antibody with a flu-orochrome dye. Antibodies can be made fluorescent by attachingthem to a dye. Direct immunofluorescence tests on skin are tech-niques to detect autoantibodies directed against portions of theskin. The indirect immunofluorescence test detects specific anti-bodies in the patient’s serum.

PATCH TESTINGPerformed to identify substances to which the patient has devel-oped an allergy, patch testing involves applying the suspected al-lergens to normal skin under occlusive patches. The developmentof redness, fine bumps, or itching is considered a weak positivereaction; fine blisters, papules, and severe itching indicate a mod-erately positive reaction; and blisters, pain, and ulceration indi-cate a strong positive reaction (see Chap. 53).

SKIN SCRAPINGSTissue samples are scraped from suspected fungal lesions with ascalpel blade moistened with oil so that the scraped skin adheresto the blade. The scraped material is transferred to a glass slide,covered with a coverslip, and examined microscopically.

TZANCK SMEARThe Tzanck smear is a test used to examine cells from blisteringskin conditions, such as herpes zoster, varicella, herpes simplex,and all forms of pemphigus. The secretions from a suspected lesionare applied to a glass slide, stained, and examined.

WOOD’S LIGHT EXAMINATIONWood’s light is a special lamp that produces long-wave ultra-violet rays, which result in a characteristic dark purple fluores-cence. The color of the fluorescent light is best seen in a darkenedroom, where it is possible to differentiate epidermal from dermal

FIGURE 55-7 The progression of male pattern baldness.


Weber, J. W., & Kelley, J. (2003). Health assessment in nursing (2nd ed.).Philadelphia: Lippincott Williams & Wilkins.

JournalsDraelos, Z. D. (1997). Understanding African-American hair. Derma-

tology Nursing, 9(4), 227–231.Fleischer, A. B., Feldman, S. R., & Rapp, S. R. (2000). The magnitude of

skin disease in the United States. Dermatologic Clinics, 17(2), 322–327.Jaworski, C., & Gilliam, A. C. (1999). Immunopathology of the hair

follicle. Dermatologic Clinics, 17(3), 561–568.Kang, S. (2001). Photoaging: Pathogenesis, prevention and treatment.

Clinical Geriatric Medicine, 17(4), 643–659.Sun-protection behaviors used by adults for their children: U.S. (1998).

Morbidity and Mortality Weekly Report, 47(23), 48–52.Weinstock, M. A., & Rossi, J. S. (1998). The Rhode Island Sun Smart

Project: A scientific approach to skin cancer prevention. ClinicalDermatology, 16(4), 411–413.

RESOURCES AND WEBSITES

Dermatology online atlas, a cooperation between the Department of Clin-ical Social Medicine (University of Heidelberg) and the Departmentof Dermatology (University of Erlangen); http://www.dermis.net.

Foundation for Ichthyosis and Related Skin Types, 650 N. CannonAvenue, Suite 17, Lansdale, PA 19446; 215-631-1411; http://www.scalyskin.org.

Lupus Foundation, 1300 Piccard Dr., Rockville, MD 29850-4303; 301-670-9292; http://www.lupus.org.

Medscape online sources for medical information; http://www.medscape.com.

National Alopecia Areata Foundation (NAAF), P.O. Box 150760, San Rafael, CA 94915-0760; 415-472-3780; http://www.alopeciaareata.com.

National Eczema Association for Science and Education, 1220 S. W.Morrison, Suite 433, Portland, OR 97205; 415-499-3474; http://www.eczema-assn.org.

National Organization for Albinism and Hypopigmentation, P.O. Box 959,East Hampstead, NH 03826-0959; 800-473-2310; http://www.albinism.org.

National Pressure Ulcer Advisory Panel, 11250 Roger Bacon Dr., Suite 8,Reston, VA 20190-5202; 703-464-4849; http://www.npuap.org.

National Psoriasis Foundation (USA), 6600 S.W. 92nd Ave., Suite 300,Portland, OR 97223-7195; 503-244-7404; http://www.psoriasis.org.

National Rosacea Society, 800 South Northwest Highway, Suite 200,Barrington, IL 60010; 1-888-NO-BLUSH; http://www.rosacea.org.

National Vitiligo Foundation, 611 South Fleishel Ave., Tyler, TX 75701;903-531-0074; http://www.nvfi.org.

Neutrogena and Orthopharmaceuticals Products: 1-800-582-4048;http://www.neutrogena.com.

New Zealand Dermatology Society; http://www.dermnetnz.org.Skin Cancer Foundation, 575 Park Ave. S., New York, NY 10016;

1-800-SKIN-490; http://www.skincancer.org.

lesions and hypopigmented and hyperpigmented lesions fromnormal skin. The patient is reassured that the light is not harm-ful to skin or eyes. Lesions that still contain melanin almost dis-appear under ultraviolet light, whereas lesions that are devoid ofmelanin increase in whiteness with ultraviolet light.

CLINICAL PHOTOGRAPHSPhotographs are taken to document the nature and extent of theskin condition and are used to determine progress or improve-ment resulting from treatment.

Critical Thinking Exercises

1. In thinking about the skin as the first line of defense forhomeostasis, identify some of the threats to skin integritythat should be assessed when admitting a patient to the hos-pital. What impact does the type of skin care delivered haveon skin integrity? How would skin assessment of an elderlypatient differ from that of a young adult?

2. An elderly African American woman is admitted to thehospital for treatment of diabetes. What concerns should beaddressed relative to the skin and circulation in a patient withdiabetes? How will your assessment of the skin of this patientdiffer from the assessment of the skin of a Caucasian patient?

REFERENCES AND SELECTED READINGS

BooksBickley, L. S., & Szilagyi, P. G. (2003). Bates’ guide to physical examina-

tion and history taking (8th ed.). Philadelphia: Lippincott Williams& Williams.

Champion, R. H., Burton, J. L., Burns, D. A., & Breathnach, S. M.(1998). Rook/Wilkinson/Ebling textbook of dermatology (6th ed.).Boston: Blackwell Science.

Demis, D. J. (Ed.). (1998). Clinical dermatology. Philadelphia: Lippincott-Raven.

Fitzpatrick, T. B., et al. (1997). Color atlas & synopsis of clinical derma-tology (3rd ed.). New York: McGraw-Hill.

Freedberg, I. M., Eisen, A. Z., Austen, K. F., Goldsmith, S. I., Katz, S.,& Fitzpatrick, T. B. (1999). Fitzpatrick’s dermatology in general med-icine (5th ed.). New York: McGraw-Hill.

Odom, R. B., James, W. D., & Berger, T. G. (2000). Andrews’ diseasesof the skin (9th ed.). Philadelphia: W. B. Saunders.

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