Subjective Assessment

Pruritus refers to itching. It is sometimes associated with a rash.

You might start by asking: Do you currently or have you recently had any itching on your skin?

If the client’s response is affirmative, ask: Do you have the itching now? 

Additional probes may include:

Region: Where is it? 

Radiation: Has it spread anywhere else? 

Understanding: Do you know what has caused it? 

Timing: When did it start? What were you doing when it started? Is it constant or intermittent? How long does it last? 

Provocative: What makes the itchiness worse?

Palliative: What relieves it?

Quality: How would you describe the itchiness? 

Quantity: How bad is it?

Severity: How would you rate the itchiness on a scale of 1 to 10? 0 being no itchiness and 10 being the most itchy you have ever experienced. 

Treatment: Have you treated it with anything? Did it help?

Assess whether the itching is localized or generalized.

Localized pruritus is limited to one area/region and is commonly the result of a reaction like an allergy or insect bites, scabies, parasites or fungal infestations. It can also be associated with dry skin (xerosis), as with eczema and psoriasis. 

Generalized pruritus is widespread itching that is not specific to one area/region. It can be an indication of systemic disease (kidney, liver, thyroid, rheumatic disease) or be caused by a medication reaction (e.g., opioids). 

Also assess for secondary infections, which can occur when there is breakdown of the skin from repeated scratching. 

Skin rashes can vary in qualities such as colour, texture, and pattern.

You might start by asking: Do you currently or have you recently had any rashes on your skin?

If the client’s response is affirmative, ask: Do you have any rashes now? 

Additional probes may include:

Region: Where is it? 

Radiation: Has it spread?

Understand: Do you know what is causing it?

Timing: When did it start? What were you doing when it started?

Provocative: What brings on the rash? 

Palliative: What makes it better?

Quality: How would you describe the rash? 

Quantity: How bad is it?

Treatment: Have you treated it with anything? Did it help?

Identifying skin rashes involves many considerations. With experience, you will begin to recognize common rashes and their morphology. 

Consider whether the rash is acute (new onset) or chronic (lasting more than 6 weeks) as this will give you important information about the timeline and possible exposures or underlying conditions. 

Many environmental exposures can cause skin rashes like contact dermatitis, a skin condition characterized by swelling, pain, redness, and sometimes lesions. Plants, insects, chemicals, plastics, detergents, pesticides are all possible causes. Thus, it is important to ask the client questions surrounding these factors such as have you had a recent change in the soap/body wash, lotions or laundry detergent that you use or have you been gardening or walking in the woods or long grass? Infections like scabies, lice, fleas, and bed bugs can also cause rash and pruritus. 

Nevi are moles.

You might start by asking: Have you noticed any abnormal looking moles, new moles, or changes in your moles?

If the answer is affirmative, ask the client to describe the change. Additional probes if the response is affirmative:

Region: Where is it located?

Quality: What does it look like? Has it changed in colour? Have you observed it growing in size?

Other questions: Is it itchy? Has it had any discharge like blood? Is there pain associated with the mole? Do you have any moles that do not look like your other moles? 

Most moles are benign (harmless). However, new moles and moles that are painful or bleed warrant further questioning. Consider the location of the mole and whether it is a region that is exposed to ultraviolet radiation from the sun. If a mole bleeds, investigate whether it is due to scratching or whether it bleeds on its own. 

It is important to ask whether the client has any moles that do not look like their other moles. This is a telling finding and can inform your objective assessment. There is a mnemonic to assess moles (to be discussed in the Objective assessment section).

Skin discolouration and skin temperature changes. 

You might start by asking: Have you noticed any changes in skin colour or skin temperature on any areas of your body?

If the answer is affirmative, ask the client to describe the change. Additional probes if the response is affirmative:

Region/radiation: Where is it located? Have you noticed it anywhere else?

Quality/quantity: Can you describe what it looks like or feels like? How bad is it?

Provocative/palliative: What makes it better? What makes it worse? 

Timing/treatment: When did you notice it? Is it constant or intermittent? If intermittent, how long does it last for? Have you tried treating it with anything? Have you sought treatment for it? Is it affected by position change (e.g., standing all day or elevating your feet? Is it worse at the end of the day?

Understanding: Do you know what is causing it?

Hormonal changes during pregnancy can cause patchy regions of dark skin pigmentation (melasma). Other skin variations associated with pregnancy include linea nigra (a darkened vertical line that runs down the abdomen) and striae (also known as stretch marks), which are indented streaks that appear on the abdomen and breasts during pregnancy – linea nigra and striae are normal findings that are part of pregancy. Some of these variations resolve after pregnancy (e.g., linea nigra) or lighten in colour (e.g., striae) and are not of concern. 

Linea nigra.

(Attribution: Photo by Warinhari – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=47136053)

Striae.

(Attribution: Photo by Emilymiller123 – Otto J. Placik, M.D., CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=6972012, cropped for OER)

Ulcers are open sores on the skin.

You might start by asking: Have you noticed any sores anywhere on your body, such as on your legs or feet, that are slow to heal?

Additional probes if the response is affirmative:

Region/radiation: Where are they located? Have you noticed them anywhere else?

Quality: What do they look like? Are the sores open? Are they wet or dry? Do you notice a discharge? If so, what colour is it?

Timing: When did the sore begin? Do you know how it developed

Treatment: Have you treated it with anything

Understanding: Do you know what is causing it? 

These sores are often caused by an injury to the skin, even a minor injury. Because ulcers are open to the air, they can act as an entry point for bacteria and can become infected and increase in size. 

They can be associated with a variety of conditions. For example, they may begin as a pressure injury over a bony prominence with clients who have mobility issues. They can also be associated with peripheral vascular diseases including arterial and venous issues (more will be discussed on these conditions in a later chapter).

Nail changes can include changes in consistency, texture, and colour.

You might start by asking: Have you noticed any changes in your nails on your hands or feet?

If the client’s response is affirmative, ask: Tell me about the changes? 

Additional probes may include:

Region: What nails are involved?

Radiation: Have you noticed it spreading?

Quality: How would you describe it?

Quantity: How bad is it?

Provocative: Is there anything that makes it worse

Palliative: Is there anything that makes it better?

Timing: When did you notice the change beginning? Is it constant or intermittent? If intermittent, how long does it last? 

Understanding: Do you know what is causing the change?

Changes to the nails may be the result of a trauma to the nail or could be a sign of disease. A detailed subjective assessment will inform how to proceed with care. 

Colour changes can include white lines, darkening of the nail, or cyanosis.

Texture changes to the nail can include a thickening of the nail, as with fungal infections. A thickening and overgrowth that looks like a ram’s horn is called onychogryphosis. Pitted nails can be a sign of psoriasis, atopic dermatitis, or alopecia. A ridge or deep groove in the nail is often referred to as Beau’s line; it is typically a sign that the nail has stopped or slowed in growth. 

Changes to the shape of the nail are also noteworthy. Clubbed nails refers to nails that start to curve, and the nails can become spongy; clubbing can be a sign of cardiopulmonary disease. Spoon-shaped nails often have a tip in the centre of the nail that runs downward. This can be a sign of malnourishment, as with iron and vitamin deficiency. 

Lifting of the nail can be the result of a fungal infection or trauma from cleaning or manicuring the nails. Onycholysis refers to a nail separating from the underlying tissue. Ingrown toenail refers to a nail growing into tissue; this causes pain, inflammation, and swelling, and can lead to infection.

Alopecia refers to hair loss, which can include thinning of the hair or complete loss of the hair on any part of the body. 

You might start by asking: Have you noticed any hair loss on your body or head?

If the client’s response is affirmative, ask: Tell me about it? 

Additional probes may include:

Region: Where have you noticed it?

Region: Has it spread anywhere?

Timing: When did it start? What was going on in your life when it began? Was it abrupt or did it come on slowly

Understanding: Do you know what might be causing it

Provocative: What brings on the hair loss? 

Palliative: Does anything make it better?

Quality: How would you describe the hair loss? 

Quantity: How bad is it?

Severity: How would you rate the hair loss on a scale of 0 to 10, with 0 being no loss at all and 10 being very bad hair loss?

Treatment: Have you treated it with anything? Has it worked?

Consider whether the hair loss was sudden or gradual. Sudden onset of hair loss can be related to alopecia areata, an auto-immune response in which the body mistakenly attacks the hair follicles. Telogen effluvium is excessive diffuse hair loss. When abrupt, it can be brought on by a triggering life event (stress, traumatic event) or by drugs, thyroid disease, or labour/birth. It is often temporary but can continue for 3–6 months after the event. 

Hair loss can be damaging to the client’s self-concept so it is important to treat them with empathy. 

Other integumentary-related symptoms can include xerosis (dry skin), seborrhea (oily skin), bruising, fatigue and fever. 

Always ask one question at a time. You might start by asking:

Have you experienced any body fatigue? (Or fever, bruising, dry or oily skin?)

Use variations of the PQRSTU mnemonic to assess symptoms further if the client’s response is affirmative.

Symptoms of fatigue and fever can be related to other body systems and non-integumentary issues. To determine whether they are integumentary-related, explore these symptoms along with any other associated symptoms.

Personal and family history of integumentary conditions and diseases. 

Some common issues associated with the integumentary system include eczema and psoriasis.

You might start by asking: 

Do you have any chronic conditions or diseases that affect your skin, hair, and nails? Do you have a familial history of conditions or diseases that affect the skin, hair, and nails? Do you have a family member with skin cancer?

If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disorder/disease?

If the client has a personal history, probing questions might include:

Timing: When did you begin experiencing symptoms related to this condition? When were you diagnosed? Are the symptoms constant or intermittent?

Quality/quantity: How does it affect you? What symptoms do you have? How bad are the symptoms

Treatment: How is it treated? Have you had any surgeries? Do you take medication?

Provocative/palliative: Does anything make it worse? Does anything make it better?

Understanding: What personal or family history do you think is important for me to understand? 

A previous history of illness (including current illness) can be an important finding that warrants further assessment. Immune deficiencies (sometimes referred to as being immuno-compromised) can decrease the body’s defences against harmful matter, rendering persons more susceptible to integumentary conditions. With auto-immune disorders, the body mistakes its own cells for foreign cells and activates an immune response. Many auto-immune disorders involve the integumental system, including lupus, scleroderma, Grave’s disease, psoriasis, and rheumatoid arthritis. Common symptoms related to auto-immune disease include fatigue, joint pain and inflammation, digestive issues, and swollen lymph nodes. 

A first-degree relative (parent, sibling) with a history of skin cancer is an important finding in your subjective assessment. Family history is important because of genetic susceptibility, but also because of shared lifestyle including environmental and behavioural factors. Always take a detailed history including age of onset, type of skin cancer, and treatment outcomes. 

Family history can provide some insights into predisposition to other conditions related to the integumental system, such as rosacea.