dam93732_ch11.qxd 12/7/05 6:38 AM Page 190 190 CHAPTER 11 Skin, Hair, and Nails Ta b le 11.1 Color Variations in Light and Dark Skin COLOR VARIATION/ APPEARANCE IN APPEARANCE IN LOCALIZATION POSSIBLE CAUSES LIGHT SKIN DARK SKIN Pallor Loss of color in skin due to the May be caused by sympathetic White skin loses its rosy tones. Black skin loses its red undertones absence of oxygenated hemoglobin. nervous stimulation resulting in Skin with natural yellow tones and appears ash-gray. Brown skin Widespread, but most apparent in peripheral vasoconstriction due to appears more yellow; may be becomes yellow-tinged. Skin looks face, mouth, conjunctivae, and nails. smoking, a cold environment, or mistaken for mild jaundice. dull. stress. May also be caused by decreased tissue perfusion due to cardiopulmonary disease, shock and hypotension, lack of oxygen, or prolonged elevation of a body part. May also be caused by anemia. Absence of Color Congenital or acquired loss of Generalized depigmentation may Albinism appears as white skin, Albinism appears as white skin, melanin pigment. be caused by albinism. Localized white or pale blond hair, and pink white or pale blond hair, and pink Congenital loss is typically depigmentation may be due to irises. Vitiligo appears as patchy irises. Vitiligo is very noticeable as generalized, and acquired loss is vitiligo or tinea versicolor, a milk-white areas, especially around patchy milk-white areas. Tinea typically patchy. common fungal infection. the mouth. Tinea versicolor versicolor appears as patchy areas appears as patchy areas paler than paler than the surrounding skin. the surrounding skin. Cyanosis Mottled blue color in skin due to Systemic or central cyanosis is due The skin, lips, and mucous The skin may appear a shade inadequate tissue perfusion with to cardiac disease, pulmonary membranes look blue-tinged. The darker. Cyanosis may be oxygenated blood. disease, heart malformations, and conjunctive and nail beds are blue. undetectable except for the lips, Most apparent in the nails, lips, oral low hemoglobin levels. Localized tongue, and oral mucous mucosa, and tongue. or peripheral cyanosis is due to membranes, nail beds, and vasoconstriction, exposure to cold, conjunctivae, which appear pale or and emotional stress. blue-tinged. Reddish Blue Tone Ruddy tone due to an increased Polycythemia vera, an Reddish purple hue. Difficult to detect. The normal skin hemoglobin and stasis of blood in overproduction of red blood cells, color may appear darker in some capillaries. granulocytes, and platelets. clients. Check lips for redness. Most apparent in the face, mouth, hands, feet, and conjunctivae. Erythema Redness of the skin due to increased Hyperemia, a dilatation and Readily identifiable over entire Generalized redness may be visibility of normal oxyhemoglobin. congestion of blood in superficial body or in localized areas. Local difficult to detect. Localized areas Generalized, or on face and upper arteries. Due to fever, warm inflammation and redness are of inflammation appear purple or chest, or localized to area of environment, local inflammation, accompanied by higher darker than surrounding skin. May inflammation or exposure. allergy, emotions (blushing or temperature at the site. be accompanied by higher embarrassment), exposure to temperature, hardness, swelling. extreme cold, consumption of alcohol, dependent position of body extremity. Jaundice Yellow undertone due to increased Increased bilirubin may be due to Generalized. Also visible in sclerae, Visible in the sclerae, oral mucosa, bilirubin in the blood. liver disease, biliary obstruction, or oral mucosa, hard palate, junction of hard and soft palate, Generalized, but most apparent in hemolytic disease following fingernails, palms of hands, and palms of the hands, and soles of the conjunctivae and mucous infections, severe burns, or soles of the feet. the feet. membranes. resulting from sickle cell anemia or pernicious anemia. Carotenemia Yellow-orange tinge caused by Excess carotene due to ingestion Yellow-orange seen in forehead, Yellow-orange tinge most visible in increased levels of carotene in the of foods high in carotene such as palms, soles. No yellowing of palms of the hands and soles of the blood and skin. carrots, egg yolks, sweet potatoes, sclerae or mucous membranes. feet. No yellowing of sclerae or Most apparent in face, palms of the milk, and fats. Also may be seen in mucous membranes. hands, and soles of the feet. clients with anorexia nervosa or endocrine disorders such as diabetes mellitus, myxedema, and hypopituitarism. ©2007 Pearson Education, Inc. dam93732_ch11.qxd 12/7/05 6:38 AM Page 191 Gathering the Data 191 Ta b le 11.1 Color Variations in Light and Dark Skin (continued) COLOR VARIATION/ APPEARANCE IN APPEARANCE IN LOCALIZATION POSSIBLE CAUSES LIGHT SKIN DARK SKIN Uremia Pale yellow tone due to retention of Chronic renal disease, in which Generalized pallor and yellow Very difficult to discern because urinary chromogens in the blood. blood levels of nitrogenous wastes tinge, but does not affect the yellow tinge is very pale and Generalized, if perceptible. increase. Increased melanin may conjunctivae or mucous does not affect conjunctivae or also contribute, and anemia is membranes. Skin may show mucous membranes. Rely on usually present as well. bruising. laboratory and other data. Brown An increase in the production and May be due to Addison’s disease With endocrine disorders, general With endocrine disorders, general deposition of melanin. or a pituitary tumor. Localized bronzed skin. Hyperpigmentation deepening of skin tone. Generalized or localized. increase in facial pigmentation may in nipples, palmar creases, genitals, Hyperpigmentation in nipples, be caused by hormonal changes and pressure points. Sun exposure genitals, and pressure points. Sun during pregnancy or the use of causes red tinge in pale skin, and exposure leads to tanning in birth control pills. More commonly olive-toned skin tans with little or various degrees from brown to due to exposure to ultraviolet no reddening. black. radiation from the sun or from tanning booths. ©2007 Pearson Education, Inc. A ssessment of the integumentary system includes gather- of difficulties, identify measures to alleviate problems, and pro- ing subjective and objective data about the skin, hair, and nails. vide clues about the client’s knowledge of his or her own health. Subjective data collection occurs during the interview, before The focused interview guides the physical assessment of the the actual physical assessment. The nurse will use a variety of integumentary system. The information is always considered in communication techniques to elicit general and specific infor- relation to norms and expectations about the function of the in- mation about the condition of the client’s skin, hair, and nails. tegument. Therefore, the nurse must consider age, gender, race, Health records and the results of laboratory tests are important culture, environment, health practices, and past and concurrent secondary sources to be reviewed and included in the data- problems and therapies when forming questions and using gathering process. In physical assessment of the integumentary techniques to elicit information. In order to address all of the system, the techniques of inspection and palpation will be used. factors when conducting a focused interview, categories of ques- The questions in the focused interview form part of the subjec- tions related to the status and function of each part of the in- tive data and provide valuable information to meet the objec- tegumentary system have been developed. These categories tives related to integumentary health included in the Healthy include general questions that are asked of all clients; those ad- People 2010 feature on page 229. dressing illness or infection; questions related to symptoms, pain, or behaviors; those related to habits or practices; questions FOCUSED INTERVIEW that are specific to clients according to age; those for pregnant females; and questions that address environmental concerns. The focused interview for the integumentary system concerns The nurse must consider the client’s ability to participate in data related to the structures and functions of that system. Sub- the focused interview and physical assessment. Further, the jective data related to the condition of the skin, hair, and nails nurse must consider that the appearance of the skin has an im- are gathered during the focused interview. The nurse must be pact on self-image. A client with clear, healthy skin may have a prepared to observe the client and listen for cues related to the heightened self-esteem. Clients with changes in the skin due to integumentary system. The nurse may use closed or open- the normal aging process or from skin disorders may be anx- ended questions to obtain information. A number of follow-up ious about the way they appear to others. Clients with visible questions or requests for descriptions may be required to clar- skin disorders are often sensitive about the condition and their ify data or gather missing information. Follow-up questions are appearance. The nurse must select communication techniques used to identify the source of problems, determine the duration that demonstrate caring and preserve the dignity of the client..