Skin, Hair, and Nails; Interpersonal Violence and Health Assessment – Structured Study Notes

Skin, Hair, and Nails

Structure and Function

The skin is the largest organ of the body, serving as a protective barrier and playing a vital role in homeostasis. It consists of multiple layers and associated appendages.

• Layers of Skin:

  • Epidermis: Outermost layer, includes the stratum germinativum (basal cell layer) and stratum corneum (horny cell layer).

  • Dermis: Middle layer, composed of connective tissue (collagen) and elastic tissue.

  • Subcutaneous Layer: Deepest layer, made of adipose (fat) tissue.

• Epidermal Appendages:

  • Hair

  • Sebaceous glands

  • Sweat glands

  • Nails

Function of the Skin

The skin performs several essential functions for the body:

• Protection: Shields against physical, chemical, thermal, and light wave injury.

• Prevents Penetration: Acts as a barrier to microorganisms.

• Perception: Contains sensory receptors for touch, pain, temperature, and pressure.

• Temperature Regulation: Dissipates heat via sweat glands.

• Identification: Unique features such as fingerprints.

• Communication: Vascular responses (e.g., blushing, blanching) signal emotional states.

• Wound Repair: Facilitates healing of injuries.

• Absorption and Excretion: Limited excretion of metabolic wastes.

• Production of Vitamin D: Synthesizes vitamin D from sunlight.

Developmental Considerations

Skin structure and function change across the lifespan:

• Infants and Children:

  • Newborns: Thin skin, increased permeability, higher risk for fluid loss, ineffective temperature regulation.

  • Puberty: Increased sweat gland activity, more active sebaceous glands, secondary sex characteristics.

• Pregnant Women: May develop linea nigra, chloasma, striae gravidarum; increased sweat/sebaceous gland secretion, fat deposits.

• Older Adults: Loss of elasticity, collagen, subcutaneous fat; decreased sweat/sebaceous gland activity.

Assessment of Skin, Hair, and Nails

Assessment includes both subjective and objective components to evaluate health status.

• Subjective Assessment: Ask about previous history, changes in pigmentation, moles, dryness/moisture, pruritus, bruising, rashes/lesions, medications, hair loss, nail changes, environmental/occupational hazards, and self-care.

• Additional History for Older Adults: Inquire about recent changes, delayed wound healing, pruritus, skin pain, changes in feet/toenails, bunions, and falls.

• Objective Assessment:

  • Inspect and palpate skin for colour (pigmentation, moles), widespread colour changes (pallor, erythema, cyanosis, jaundice), temperature, moisture, texture, thickness, edema (rate using edema scale), mobility & turgor, vascularity/bruising, and lesions.

  • Inspect and palpate hair for colour, texture, distribution, and lesions.

  • Inspect and palpate nails for shape, contour (profile sign), consistency, and colour (capillary refill).

Developmental Considerations: Skin Variations

• Infant: Mongolian spots, milia

• Child: Common rashes, bruising

• Adolescents: Acne, increased oiliness

• Pregnant Female: Pigmentation changes, striae

• Older Adults: Lentigines, skin tags, thinning skin

Primary Skin Lesions

Primary skin lesions are the initial, direct result of a pathological process.

• Macule: Flat, circumscribed, Examples: Freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

• Papule: Palpable, solid, elevated, circumscribed, Examples: Elevated nevus (mole), lichen planus, molluscum, wart (verruca).

• Patch: Macules >1cm diameter. Examples: Congenital dermal melanocytosis, vitiligo, café au lait spot, chloasma, measles rash.

• Plaque: Papules that coalesce to form surface elevation wider than 1cm; plate-like, disc-shaped. Examples: Psoriasis, lichen planus.

• Nodule: Solid, elevated, hard or soft, >1cm diameter; may extend deeper into dermis than papule. Examples: Xanthoma, fibroma, intradermal nevi.

• Wheal: Superficial, raised, transient, erythematous; slightly irregular shape due to edema. Examples: Mosquito bite, allergic reaction, dermographism.

Types of Lesions

• Vesicle: Elevated cavity containing free fluid, up to 1cm; clear serum flows if wall is ruptured. Examples: Herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis.

• Bulla: Single-chambered (unilocular), superficial in epidermis, >1cm diameter; thin-walled, ruptures easily. Examples: Friction blister, pemphigus, burns, contact dermatitis.

• Cyst: Encapsulated fluid-filled cavity in dermis or subcutaneous layer; tensely elevates skin. Examples: Sebaceous cyst.

• Pustule: Cavity filled with turbid fluid (pus); circumscribed and elevated. Examples: Impetigo, acne.

Matching Activity: Lesion Types

The following table matches lesion descriptions to their names:

Description	Lesion Type
Tiny punctate hemorrhages, 1–3 mm, round and discrete, dark red, purple, or brown in colour	Petechiae
A hypertrophic scar	Keloid
Solid, elevated, hard or soft, larger than 1 cm	Nodule
Also known as a friction blister	Bulla
Large patch showing capillary bleeding into tissues	Ecchymosis
Elevated cavity containing free fluid, up to 1 cm; clear serum flows if wall is ruptured	Vesicle

Health Promotion

• Teach Self Skin Examination (SSE): Instruct clients on regular self-examination for early detection of skin changes.

• Sun Care: Educate on sun protection to reduce risk of skin cancer.

• ABCDE Skin Assessment: Use the ABCDE criteria to assess moles for melanoma risk.

Teaching Skin Self-Examination (SSE)

• Why: Early detection of skin changes and skin cancer.

• Who: All individuals, especially those at higher risk.

• Frequency: Regular intervals, as recommended by health professionals.

• Technique: Demonstrate order and body positioning for thorough inspection.

ABCDE Skin Assessment

The ABCDE criteria help identify suspicious moles and lesions for melanoma:

• A – Asymmetry: Benign moles are symmetrical; asymmetry is a warning sign.

• B – Border: Benign moles have smooth, even borders; malignant ones may be uneven, scalloped, or notched.

• C – Color: Benign moles are uniform in color; malignant ones may have multiple colors or shades.

• D – Diameter: Benign moles are usually smaller; malignant ones are often larger than 6mm.

• E – Evolving: Changes in size, shape, color, or symptoms (bleeding, itching, crusting) indicate danger.

Braden Scale

The Braden Scale is a clinical tool for predicting pressure sore risk. It consists of six subscales:

• Sensory perception

• Moisture

• Activity

• Mobility

• Nutrition

• Friction and shear

Score ranges from 6 to 23; lower scores indicate higher risk of pressure ulcer development.

Subscale	1 (Most Impaired)	2	3	4 (Least Impaired)
Sensory Perception	Completely limited	Very limited	Slightly limited	No impairment
Moisture	Constantly moist	Very moist	Occasionally moist	Rarely moist
Activity	Bedfast	Chairfast	Walks occasionally	Walks frequently
Mobility	Completely immobile	Very limited	Slightly limited	No limitation
Nutrition	Very poor	Probably inadequate	Adequate	Excellent
Friction & Shear	Problem	Potential problem	No apparent problem	—

Objective Assessment Tips

• Integrate skin assessment throughout the examination.

• Check all areas of the body, especially with rashes, as history may be unreliable.

• Inspect skinfolds (under breasts, obese abdomen, groin) thoroughly.

• Pay special attention to feet.

Interpersonal Violence and Health Assessment

Interpersonal Violence

Interpersonal violence (IPV) is a significant public health issue, encompassing various forms of abuse and maltreatment.

• Definition: Includes intimate partner violence, sexual assault, child maltreatment, and elder abuse.

• Prevalence: Many individuals have histories of or are experiencing ongoing violence.

Intimate Partner Violence (IPV)

IPV is always an abuse of power and can occur in various relationship contexts.

• Forms of Abuse: Physical/sexual violence, psychological violence, financial abuse.

• Contexts: Current/former intimate, marital, common-law, and same-sex relationships.

• Examples: Physical/sexual assault, verbal abuse, imprisonment, humiliation, stalking, denial of access to resources, shelter, services, children, or family members.

• Risk Factors: Gender is a key risk factor for experiencing IPV.

References

• Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2024). Physical examination and health assessment (4th ed.). Elsevier Canada.