COLLECTING OBJECTIVE DATA: INTEGUMENTARY e.

Jaundice in light and darkskinned people is

A. Equipment characterized by yellow skin tones, from pale to
1. Examination light pumpkin, particularly in the sclera, oral mucosa,
2. Penlight palms, and soles.Jaundice associated with hepatic
3. Mirror for client’s self-examination of skin dysfunction.
4. Magnifying glass
5. Centimeter ruler
6. Gloves
7. Wood’s light
8. Examination gown or drape
9. Braden Scale for Predicting Pressure Sore Risk
10. Pressure Ulcer Scale for Healing (PUSH) tool to
measure pressure ulcer healing f.

B. Physical Assessment
When preparing to examine the skin, hair, and nails,
remember these key points: Acanthosis nigricans is roughening and darkening of skin
1. Inspect skin color, temperature, moisture, texture. in localized areas, especially the posterior neck.
2. Check skin integrity.
3. Be alert for skin lesions.
4. Evaluate hair condition; loss or unusual growth.
5. Note nail bed condition and capillary refill.

C. Procedure
1. Inspect general skin coloration
Normal findings:
• Inspection reveals evenly colored skin tones without
unusual or prominent discolorations.
• CULTURAL CONSIDERATIONS 2. While inspecting skin coloration, note any odors
• Small amounts of melanin are common in pale or emanating from the skin.
light skins, while large amounts of melanin are • Normal findings:
common in olive and darker skins. • Client has slight or no odor of
• Carotene accounts for a yellow cast. perspiration, depending on activity.
• OLDER ADULTCONSIDERATIONS • Abnormal findings:
• The older client’s skin becomes pale due to • A strong odor of perspiration or foul
decreased melanin production and decreased odor may indicate disorder of sweat
dermal vascularity. glands. Poor hygiene practices may
Abnormal findings: indicate a need for client teaching or
a. Pallor (loss of color) is seen in arterial insufficiency, assistance with activities of daily living.
decreased blood supply, and anemia. Pallid tones 3. Inspect for color variations.
vary from pale to ashen without underlying pink. • Inspect localized parts of the body, noting any color
variation
b. Cyanosis may cause white skin to appear blue- • Normal findings;
tinged, especially in the perioral, nail bed, and • Common variations include suntanned
conjunctival areas. Dark skin may appear blue, dull, areas, freckles, or white patches known
and lifeless in the same areas.Bluish cyanotic skin as vitiligo. The variations are due to
associated with oxygen deficiency. different amounts of melanin in certain
areas.
c. Central cyanosis results from a cardiopulmonary • A generalized loss of pigmentation is
problem, whereas peripheral cyanosis may be a local seen in albinism.
problem resulting from vasoconstriction. • Dark-skinned clients have lighter-
d. To differentiate between central and peripheral colored palms, soles, nail beds, and lips.
cyanosis, look for central cyanosis in the oral • Freckle-like or dark streaks of
mucosa. pigmentation are also common in the
sclera and nail beds of dark-skinned • CULTURAL CONSIDERATIONS
clients. • Pale or light-skinned clients have
darker pigment around nipples, lips,
and genitalia.
• Abnormal findings:
• Abnormal findings include rashes, such asthe
reddish (in light-skinned people) or darkened (in
dark-skinned people) butterfly rash (also called
Malar rash) across the bridge of the nose and
cheeks , characteristic of systemic lupus
erythematosus (SLE).
• SLE is seen in a 9:1 female-to-male ratio and is
more common in black and Hispanic people
• Characteristic butterfly rash of lupus
erythematosus

Erythema (skin redness and warmth) is seen in

inflammation, allergic reactions, or trauma.
• Erythema in the dark-skinned client may be difficult
to see. However, the affected skin feels swollen and
warmer than the surrounding skin.
• Procedure
4. Check skin integrity.
• Pay special attention to pressure point areas
• Use the Braden Scale to predict pressure sore risk.
• If any skin breakdown is noted, use the PUSH tool to
document the degree of skin breakdown.
• In the obese client, carefully inspect skin on the
limbs, under breasts, and in the groin area where
problems are frequent due to perspiration and
friction.

Normal findings;
• Skin is intact, and there are no reddened areas.
Abnormal findings:
• Skin breakdown is initially noted as a reddened area
on the skin that may progress to serious and painful pressure
ulcers
• Depending on the color of the client’s skin, reddened
areas may not be prominent, although the skin may feel
warmer in the area of breakdown than elsewhere.
• Pressure ulcer stage I
• Pressure ulcer stage II • Freckles or moles may be scattered over the skin in
no particular pattern.
• Scarifications may be used by some individuals who
want to have a scar or keloid. These scars may be created by
branding with a hot metal burn or cutting with a knife or
scalpel (American Academy of Dermatology, 2010).
• Pressure ulcer stage III Abnormal findings:
• Lesions may
indicate local or systemic
problems. Primary lesions
arise from normal skin due
to irritation or disease.
• Secondary lesions
arise from changes in
primary lesions. Vascular
• Pressure ulcer stage IV lesions, reddish-bluish
• Common pressure ulcer sites lesions, are seen with
bleeding, venous pressure, aging, liver disease, or pregnancy.

PRIMARY LESSION
a. MACULE AND PATCH
• Small, flat,
nonpalpable skin color
change (skin color maybe
brown, white, tan, purple,
red).
• Macules are less
than 1 cm with a
circumscribed border,
whereas patches are greater than 1 cm, and may have an
irregular border.
• Examples include freckles, flat moles, petechiae,
rubella (pictured below), vitiligo, port wine stains, and
ecchymosis.

5. Inspect for lesions.

b. PAPULE AND PLAQUE
• Observe the skin surface to detect abnormalities.
• E l e v a t
• If you observe a lesion:
• Note color, shape, and size of lesion. For very small
lesions, use a magnifying glass to note these characteristics.
• Note its location, distribution, and configuration.
• Measure the lesion with a centimeter ruler.
Normal Findings
border and are less than 0.5 cm; plaques are greater than 0.5
• Skin is smooth, without lesions. Stretch marks
cm and may be coalesced papules with a flat top.
(striae), healed scars, freckles, moles, or birthmarks are
• Examples of papules include elevated nevi, warts,
common findings
and lichen planus.
• Examples of plaques include psoriasis (psoriasis
vulgaris pictured below) and actinic keratosis.

e. WHEAL
• Elevated mass with transient borders that is often
irregular.
c. NODULE AND TUMOR • Size and color vary. Caused by movement of serous
• Elevated, solid, palpable mass that extends deeper fluid into the dermis;
into dermis than a papule. Nodules are 0.5–2 cm and • it does not contain free fluid in a cavity (e.g., vesicle).
circumscribed; tumors are greater than 1–2 cm and do not • Examples include urticariaand insect bites.
always have sharp borders. .
• Examples of nodules include keloid(pictured below),
lipoma, squamous cell carcinoma, poorly absorbed injection,
and dermatofibroma.
• Examples of tumors include larger lipoma and
carcinoma.

f. PUSTULE
• Pus-filled vesicle or bulla. Examples include acne,
impetigo, furuncles, and carbuncles.

g. CYST
• Encapsulated fluid-filled or semisolid mass that is
located in the subcutaneous tissue or dermis. Examples
include sebaceous cyst and epidermoid cyst (pictured below).
Abnormal findings:
• Cancerous lesions can be either primary or
secondary lesions and are classified as squamous cell
carcinoma, basal cell carcinoma, or malignant
• If you suspect a fungus, shine a Wood’s light (an
d. VESICLE AND BULLA ultraviolet light filtered through a special glass) on the lesion.
• Circumscribed elevated, palpable mass containing • Lesion does not fluoresce.
serous fluid. Vesicles are less than 0.5 cm; bullas are greater • Blue-green fluorescence indicates fungal infection.
than 0.5 cm. • Procedure
• Examples of vesicles include herpes simplex/ zoster, 6. Palpate skin to assess texture.
varicella, poison ivy, and second-degree burn. • Use the palmar surface of your three middle fingers
• Examples of bulla include pemphigus, contact to palpate skin texture.
dermatitis, large burn blisters, poison ivy, and bullous Normal findings:
impetigo. • Skin is smooth and even.
• Procedure
Abnormal findings: • Normally, the skin is mobile, with elasticity and
• Rough, flaky, dry skin is seen in hypothyroidism. returns to original shape quickly.
• Obese clients often report dry, itchy skin. OLDER ADULT CONSIDERATIONS
• Procedure • The older client’s skin loses its turgor because of a
7. Palpate to assess thickness. decrease in elasticity and collagen fibers.
• If lesions are noted when assessing skin thickness, • Sagging or wrinkled skin appears in the facial, breast,
put gloves on and palpate the lesion between the thumb and and scrotal areas.
index finger for size, mobility, consistency, and tenderness • Decreased mobility is seen with edema.
• Observe for drainage or other characteristics. • Decreased turgor (a slow return of the skin to its
• If lesions are noted when assessing skin thickness, normal state taking longer than 30 seconds) is seen in
put gloves on and palpate the lesion between the thumb and dehydration.
index finger for size, mobility, consistency, and tenderness • Palpating to assess skin turgor
• Observe for drainage or other characteristics. and mobility.
Normal findings:
• No lesions palpated.
Abnormal findings:
• Infected lesions may be tender to palpate.
• Nonmobile, fixed lesions may be cancer.
8. Palpate to assess moisture.
• Check under skin folds and in unexposed areas.
• Some nurses believe that using the dorsal surfaces of
the hands to assess moisture leads to a more accurate result.
• Procedure 11. Palpate to detect edema.
Normal findings: • Use your thumbs to press down on the skin of the
• Skin surfaces vary from moist to dry depending on feet or ankles to check for edema (swelling related to
the area assessed. Recent activity or a warm environment accumulation of fluid in the tissue).
may cause increased moisture. Normal findings:
OLDER ADULT CONSIDERATIONS • Skin rebounds and does not remain indented when
• The older client’s skin may feel dryer than a younger pressure is released.
client’s skin because sebum production decreases with age. • Procedure
Abnormal findings: Abnormal findings:
• Increased moisture or diaphoresis (profuse sweating) • Indentations on the skin may vary from slight to
may occur in conditions such as fever or hyperthyroidism. great and may be in one area or all over the body.
• Decreased moisture occurs with dehydration or 12. Inspect the scalp and hair for general color and condition.
hypothyroidism. Normal findings:
• Clammy skin is typical in shock or hypotension. • Natural hair color, as opposed to chemically colored
9. Palpate to assess temperature. hair, varies among clients from pale blond to black to gray or
• Use the dorsal surfaces of your hands to palpate the white. The color is determined by the amount of melanin
skin present.
Normal findings: • Procedure
• Skin is normally a warm temperature. • At 1-inch intervals, separate the hair from the scalp
Abnormal findings: and inspect and palpate the hair and scalp for cleanliness,
• Cold skin may accompany shock or hypotension. dryness or oiliness, parasites, and lesions
Cool skin may accompany arterial disease. • Wear gloves if lesions are suspected or if hygiene is
• Very warm skin may indicate a febrile state or poor.
hyperthyroidism. • Scalp is clean and dry. Sparse dandruff may be
• Assessing temperature and moisture visible. Hair is smooth and firm, somewhat elastic.
10. Palpate to assess mobility and turgor. OLDER ADULT CONSIDERATIONS
• Ask the client to lie down. Using two fingers, gently • As people age, hair feels coarser and drier.
pinch the skin over the clavicle. CULTURAL CONSIDERATIONS
• Mobility refers to how easily the skin can be pinched. • Individuals of black African descent often have very
Turgor refers to the skin’s elasticity and how quickly the skin dry scalps and dry, fragile hair, which the client may condition
returns to its original shape after being pinched. with oil or a petroleum jelly–like product. (This kind of hair is
• Procedure
of genetic origin and not related to thyroid disorders or
nutrition. Such hair needs to be handled very gently.)
Abnormal findings:
• Nutritional deficiencies may cause patchy gray hair in
some clients. Severe malnutrition in African American
children may cause a copperred hair color
• Excessive scaliness may indicate dermatitis.
• Raised lesions may indicate infections or tumor
growth.
• Dull, dry hair may be seen with hypothyroidism and
malnutrition.
• Poor hygiene may indicate a need for client teaching
or assistance with activities of daily living.
• Pustules with hair loss in patches are seen in tinea
capitis, a contagious fungal disease
• Infections of the hair follicle (folliculitis) appear as
pustules surrounded by erythema.
• Folliculitis of the scalp.
• Folliculitis of the beard area.
• Patchy hair loss.

13. Inspect amount and distribution of scalp, body, axillae,

and pubic hair.
Look for unusual growth elsewhere on the body.
Normal findings:
• OLDER ADULTCONSIDERATIONS
• Varying amounts of terminal hair cover the scalp,
axillary, body, and pubic areas according to normal gender
distribution. Fine vellus hair covers the entire body except for
the soles, palms, lips, and nipples. Normal male pattern
balding is symmetric
• Older clients have thinner hair becauseof a decrease
in hair follicles. Pubic, axillary,and body hair also decrease
withaging. Alopecia is seen, especially in
men. Hair loss occurs from the peripheryof the scalp and
moves to the center.
• Older women may have terminal hairgrowth on the
chin owing to hormonal changes.