{"id":1096,"date":"2022-12-12T11:54:04","date_gmt":"2022-12-12T16:54:04","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/subjective-assessment-4-2\/"},"modified":"2025-06-25T15:52:33","modified_gmt":"2025-06-25T19:52:33","slug":"subjective-assessment-4-2","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/subjective-assessment-4-2\/","title":{"raw":"Subjective Assessment","rendered":"Subjective Assessment"},"content":{"raw":"<span style=\"color: #000000\">Assessments of the integumentary system may be uncomfortable, embarrassing, or evoke anxiety for the client. It is possible that the client has been avoiding consultation with a healthcare provider for some time and the condition has advanced. The client may be fearful of the outcome of the assessment, for example, with concerns of malignancy. <\/span>\r\n\r\n<span style=\"color: #000000\">During your assessment, try to:<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Attend to their concerns and ensure open communication with the client while commending them for seeking care. Ignoring their stress or delayed consultation may reinforce that they should be fearful of their integumentary concern and this could affect their follow-up care.\u00a0<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Show unconditional positive regard for the client and empathy for their situation; this will help you collaborate with the client.\u00a0<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Be clear about next steps and what the client can anticipate during their consultation; this is imperative to a positive therapeutic approach.\u00a0<\/span><\/li>\r\n<\/ul>\r\n<span style=\"color: #000000\">Start the conversation with \u201cwhat brings you here today\u201d and pay attention to their response. The client may identify a particular symptom such as itchiness, swelling, or a lump. Their responses should prompt further questions to help you better understand the underlying issue. A systematic way to approach this line of questioning is to use the <a href=\"https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/chapter\/the-pqrstu-assessment\/\" target=\"_blank\" rel=\"noopener\">PQRSTU<\/a> mnemonic, which can help ensure you have covered the important basics.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">As a critical thinker, you should also consider what else may warrant further inquiry beyond the PQRSTU mnemonic. For example, you might ask about previous environmental exposures, medications (including name, dose, frequency, reason it was prescribed, how long they have been taking the medication), herbal remedies, supplements, allergies, non-prescribed substance use, and exposure to [pb_glossary id=\"1448\"]contagions[\/pb_glossary].\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">You can motivate the client to make lifestyle changes by ending the conversation with collaborative dialogue around health promotion strategies such as appropriate sunscreen application, regularly cleaning nail tools, and education about vitamins. Depending on the context, you might engage in this kind of discussion during the subjective assessment or after the objective assessment. A section on \u201cHealth Promotion Considerations and Interventions\u201d is provided later in this chapter.<\/span>\r\n<div class=\"textbox shaded\">\r\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity\u00a0<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">Western health assessment textbooks have been criticized for reinforcing a Euro-centric view of disease by largely focusing on ailments of white skin, and overlooking variations of black and brown skin. This kind of <strong>systemic racism<\/strong> can narrow the scope of knowledge of healthcare providers and can result in conditions being missed, further marginalizing racialized populations. Inclusive care requires more attention to black and brown skin variations, and this textbook is a first step. You can also access supplementary tools such as <a href=\"https:\/\/www.blackandbrownskin.co.uk\/mindthegap\" target=\"_blank\" rel=\"noopener\">Mind the Gap<\/a>\u00a0to help you recognize clinical signs in black and brown skin.\u00a0<\/span>\r\n\r\n<\/div>\r\n<span style=\"color: #000000\">Depending on the reason for seeking care, the healthcare context, and the nature of the client\u2019s visit, you may choose to start with screening questions about general health or enter immediately into a focused examination of the integument. Use your clinical judgement about the appropriateness of your questions and try to use a balanced approach between your own workload, the timing of visit, the urgency of the issue, and the nature of the healthcare setting. <strong>Table 3<\/strong> provides some examples of symptoms, questions, and clinical tips.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Table 3:<\/strong> Common symptoms, questions, and clinical tips.<\/span>\r\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%\" border=\"0\">\r\n<tbody>\r\n<tr class=\"shaded\">\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<strong>Symptoms<\/strong><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<strong>Questions<\/strong><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<strong>Clinical Tips<\/strong><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Pruritus<\/strong> refers to itching. It is sometimes associated with a rash.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking: Do you currently or have you recently had any itching on your skin?<\/span>\r\n\r\n<span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Do you have the itching now?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span>\r\n\r\n<span style=\"color: #000000\">Region: Where is it?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Radiation: Has it spread anywhere else?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Understanding: Do you know what has caused it?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Timing: When did it start? What were you doing when it started? Is it constant or intermittent? How long does it last?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Provocative: What makes the itchiness worse?<\/span>\r\n\r\n<span style=\"color: #000000\">Palliative: What relieves it?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality: How would you describe the itchiness?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Quantity: How bad is it?<\/span>\r\n\r\n<span style=\"color: #000000\">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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Treatment: Have you treated it with anything? Did it help?<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">Assess whether the itching is localized or generalized.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Localized pruritus<\/strong> 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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Generalized pruritus<\/strong> 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).\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Also assess for secondary infections, which can occur when there is breakdown of the skin from repeated scratching.\u00a0<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Skin rashes<\/strong> can vary in qualities such as colour, texture, and pattern.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking: Do you currently or have you recently had any rashes on your skin?<\/span>\r\n\r\n<span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Do you have any rashes now?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span>\r\n\r\n<span style=\"color: #000000\">Region: Where is it?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Radiation: Has it spread?<\/span>\r\n\r\n<span style=\"color: #000000\">Understand: Do you know what is causing it?<\/span>\r\n\r\n<span style=\"color: #000000\">Timing: When did it start? What were you doing when it started?<\/span>\r\n\r\n<span style=\"color: #000000\">Provocative: What brings on the rash?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Palliative: What makes it better?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality: How would you describe the rash?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Quantity: How bad is it?<\/span>\r\n\r\n<span style=\"color: #000000\">Treatment: Have you treated it with anything? Did it help?<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">Identifying skin rashes involves many considerations. With experience, you will begin to recognize common rashes and their morphology.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Consider whether the rash is <strong>acute<\/strong> (new onset) or <strong>chronic<\/strong> (lasting more than 6 weeks) as this will give you important information about the timeline and possible exposures or underlying conditions.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">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.\u00a0<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Nevi<\/strong> are moles.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking: Have you noticed any abnormal looking moles, new moles, or changes in your moles?<\/span>\r\n\r\n<span style=\"color: #000000\">If the answer is affirmative, ask the client to describe the change. Additional <strong>probes<\/strong> if the response is affirmative:<\/span>\r\n\r\n<span style=\"color: #000000\">Region: Where is it located?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality: What does it look like? Has it changed in colour? Have you observed it growing in size?<\/span>\r\n\r\n<span style=\"color: #000000\">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?\u00a0<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">Most moles are <strong>benign<\/strong> (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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">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 (<strong>to be discussed in the Objective assessment section<\/strong>).<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Skin discolouration<\/strong> and<strong> skin<\/strong> <strong>temperature changes<\/strong>.\u00a0<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking: Have you noticed any changes in skin colour or skin temperature on any areas of your body?<\/span>\r\n\r\n<span style=\"color: #000000\">If the answer is affirmative, ask the client to describe the change. Additional <strong>probes<\/strong> if the response is affirmative:<\/span>\r\n\r\n<span style=\"color: #000000\">Region\/radiation: Where is it located? Have you noticed it anywhere else?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality\/quantity: Can you describe what it looks like or feels like? How bad is it?<\/span>\r\n\r\n<span style=\"color: #000000\">Provocative\/palliative: What makes it better? What makes it worse?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">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?<\/span>\r\n\r\n<span style=\"color: #000000\">Understanding: Do you know what is causing it?<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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.\u00a0<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-288x300.png\" alt=\"A dark line down the centre of the abdomen.\" width=\"194\" height=\"202\" class=\"alignnone wp-image-1094\" \/>\r\n\r\n<span style=\"color: #000000\">Linea nigra.<\/span>\r\n\r\n<span style=\"color: #000000\">(Attribution: Photo by Warinhari - Own work, CC BY-SA 4.0,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=47136053\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=47136053<\/a><span style=\"color: #000000\">)<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks-300x192.png\" alt=\"White, silver coloured lines on the abdomen.\" width=\"195\" height=\"125\" class=\"alignnone wp-image-1095\" \/>\r\n\r\n<span style=\"color: #000000\">Striae.<\/span>\r\n\r\n<span style=\"color: #000000\">(Attribution: Photo by Emilymiller123 - Otto J. Placik, M.D., CC BY-SA 3.0,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=6972012\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=6972012<\/a><span style=\"color: #000000\">, cropped for OER)<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Ulcers<\/strong> are open sores on the skin.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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?<\/span>\r\n\r\n<span style=\"color: #000000\">Additional <strong>probes<\/strong> if the response is affirmative:<\/span>\r\n\r\n<span style=\"color: #000000\">Region\/radiation: Where are they located? Have you noticed them anywhere else?<\/span>\r\n\r\n<span style=\"color: #000000\">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?<\/span>\r\n\r\n<span style=\"color: #000000\">Timing: When did the sore begin? Do you know how it developed<\/span>\r\n\r\n<span style=\"color: #000000\">Treatment: Have you treated it with anything<\/span>\r\n\r\n<span style=\"color: #000000\">Understanding: Do you know what is causing it?\u00a0<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">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).<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Nail changes<\/strong> can include changes in consistency, texture, and colour.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking: Have you noticed any changes in your nails on your hands or feet?<\/span>\r\n\r\n<span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Tell me about the changes?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span>\r\n\r\n<span style=\"color: #000000\">Region: What nails are involved?<\/span>\r\n\r\n<span style=\"color: #000000\">Radiation: Have you noticed it spreading?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality: How would you describe it?<\/span>\r\n\r\n<span style=\"color: #000000\">Quantity: How bad is it?<\/span>\r\n\r\n<span style=\"color: #000000\">Provocative: Is there anything that makes it worse<\/span>\r\n\r\n<span style=\"color: #000000\">Palliative: Is there anything that makes it better?<\/span>\r\n\r\n<span style=\"color: #000000\">Timing: When did you notice the change beginning? Is it constant or intermittent? If intermittent, how long does it last?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Understanding: Do you know what is causing the change?<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Colour changes<\/strong> can include white lines, darkening of the nail, or cyanosis.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Texture changes<\/strong> to the nail can include a thickening of the nail, as with fungal infections. A thickening and overgrowth that looks like a ram\u2019s 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\u2019s line; it is typically a sign that the nail has stopped or slowed in growth.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Changes to the <strong>shape of the nail<\/strong> 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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Lifting of the nail<\/strong> can be the result of a fungal infection or trauma from cleaning or manicuring the nails. <strong>Onycholysis<\/strong> refers to a nail separating from the underlying tissue. <strong>Ingrown toenail<\/strong> refers to a nail growing into tissue; this causes pain, inflammation, and swelling, and can lead to infection.<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Alopecia<\/strong> refers to hair loss, which can include thinning of the hair or complete loss of the hair on any part of the body.\u00a0<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking: Have you noticed any hair loss on your body or head?<\/span>\r\n\r\n<span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Tell me about it?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span>\r\n\r\n<span style=\"color: #000000\">Region: Where have you noticed it?<\/span>\r\n\r\n<span style=\"color: #000000\">Region: Has it spread anywhere?<\/span>\r\n\r\n<span style=\"color: #000000\">Timing: When did it start? What was going on in your life when it began? Was it abrupt or did it come on slowly<\/span>\r\n\r\n<span style=\"color: #000000\">Understanding: Do you know what might be causing it<\/span>\r\n\r\n<span style=\"color: #000000\">Provocative: What brings on the hair loss?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Palliative: Does anything make it better?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality: How would you describe the hair loss?\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Quantity: How bad is it?<\/span>\r\n\r\n<span style=\"color: #000000\">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?<\/span>\r\n\r\n<span style=\"color: #000000\">Treatment: Have you treated it with anything? Has it worked?<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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\u20136 months after the event.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Hair loss can be damaging to the client\u2019s self-concept so it is important to treat them with empathy.\u00a0<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Other integumentary-related<\/strong> symptoms can include xerosis (dry skin), seborrhea (oily skin), bruising, fatigue and fever.\u00a0<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">Always ask one question at a time.\u00a0You might start by asking:<\/span>\r\n\r\n<span style=\"color: #000000\">Have you experienced any body fatigue? (Or fever, bruising, dry or oily skin?)<\/span>\r\n\r\n<span style=\"color: #000000\">Use variations of the PQRSTU mnemonic to assess symptoms further if the client\u2019s response is affirmative.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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.<\/span><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Personal<\/strong> and <strong>family history<\/strong> of integumentary conditions and diseases.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Some common issues associated with the integumentary system include eczema and psoriasis.<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">You might start by asking:\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">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?<\/span>\r\n\r\n<span style=\"color: #000000\">If the client\u2019s response is affirmative, begin with an open-ended probe: Tell me about the condition\/disorder\/disease?<\/span>\r\n\r\n<span style=\"color: #000000\">If the client has a personal history, <strong>probing questions<\/strong> might include:<\/span>\r\n\r\n<span style=\"color: #000000\">Timing: When did you begin experiencing symptoms related to this condition? When were you diagnosed? Are the symptoms constant or intermittent?<\/span>\r\n\r\n<span style=\"color: #000000\">Quality\/quantity: How does it affect you? What symptoms do you have? How bad are the symptoms<\/span>\r\n\r\n<span style=\"color: #000000\">Treatment: How is it treated? Have you had any surgeries? Do you take medication?<\/span>\r\n\r\n<span style=\"color: #000000\">Provocative\/palliative: Does anything make it worse? Does anything make it better?<\/span>\r\n\r\n<span style=\"color: #000000\">Understanding: What personal or family history do you think is important for me to understand?\u00a0<\/span><\/td>\r\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;\r\n\r\n<span style=\"color: #000000\">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\u2019s 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\u2019s disease, psoriasis, and rheumatoid arthritis. Common symptoms related to auto-immune disease include fatigue, joint pain and inflammation, digestive issues, and swollen lymph nodes.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">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.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Family history can provide some insights into predisposition to other conditions related to the integumental system, such as [pb_glossary id=\"1446\"]rosacea[\/pb_glossary].\u00a0<\/span><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div align=\"left\">\r\n\r\n&nbsp;\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<span style=\"color: #000000\">Personal protective equipment (PPE) like gloves may be necessary for skin variations that expel bodily fluids like blood or pus. Some lesions can expel with pressure when punctured and a face shield may be necessary.\u00a0<\/span>\r\n\r\nUrticaria (hives) are itchy patches and bumps that are sometime raised and look swollen. They may look lighter or darker than one\u2019s normal skin colour on clients with darker tones and they look red and dark pink on clients with lighter skin tones and sometimes with white centres. They are sometimes caused by an allergic reaction to food, medications, or a bug bite. Although they often disappear with no treatment or an antihistamine, in rare cases they could be associated with a severe allergic reaction (anaphylaxis) including symptoms of dyspnea (difficulty breathing), wheezing, tightness or swelling of the throat. Anaphylaxis is a life-threatening condition and needs to be reported and treated immediately; administration of epinephrine is a priority if anaphylaxis is suspected.\r\n\r\n<img src=\"https:\/\/www.atlasdermatologico.com.br\/img?imageId=7779\" width=\"445\" height=\"396\" class=\"alignnone\" alt=\"Patches and bumps on person's back.\" \/> <img src=\"https:\/\/www.atlasdermatologico.com.br\/img?imageId=7780\" width=\"444\" height=\"330\" class=\"alignnone\" alt=\"Raised swollen patches on person's skin.\" \/>\r\n\r\nUrticaria: Image free to use for non-commercial purposes, from: https:\/\/www.atlasdermatologico.com.br\/index.jsf\r\n\r\n<\/div>\r\n<\/div>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Knowledge Bites<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<span style=\"color: #000000\">Certain medications can cause photoreactions, which are skin reactions caused by exposure to sunlight. Consumption of certain medications can lead to photosensitivity (sensitivity to sun exposure), photo-allergy (inflammation\/allergic reaction after exposure to sun), and phototoxicity (hazardous sensitivity to sunlight that causes damage to tissue). Medications with these possible side effects include antibiotics, antihistamines, psychiatric agents, and cardiovascular drugs, as well as some topical medications.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Vitamins and some herbal remedies can also cause photoreactions and other integumentary responses. For example, niacin (vitamin B3) toxicity can cause flushing (reddened skin, itching, tingling). Excess vitamin A can cause itching, scaling, cheilitis (dry chapped lips), and even hair loss. Excess vitamin B6 can cause skin eruptions, typically after sun exposure. [pb_glossary id=\"1480\"]St. John\u2019s wort[\/pb_glossary] can cause hives and\/or other skin reactions. Other screening questions pertinent to a subjective assessment relate to personal care routines, sun exposure, and exposure to other irritants.<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">Malnutrition is associated with social determinants of health such as socioeconomic status, as well as many conditions. For example, it can be associated with alcoholism, either because of inadequate dietary intake accompanied by overconsumption of alcohol that does not contain nutrients or due to malabsorption from gastrointestinal conditions secondary to alcoholism. Persons living with alcoholism often have deficiencies in vitamin A, B1, B2, B6, C, E, and niacin, as well as other nutrient depletions like magnesium, potassium, and zinc. Chronic alcoholism can lead to skin changes related to liver disease, such as jaundice (yellowing of skin and sclera) due to bilirubin build up, hyperpigmentation, and generalized pruritus. Recognizing the signs of alcoholism is an important first step in seeking treatment. Family members are often the first to identify a problem. Always build a therapeutic relationship with the client, including unconditional positive regard; this will help establish trust and connect the client with appropriate supports.\u00a0<\/span>\r\n\r\n<\/div>\r\n<h2><span>Activity: Check Your Understanding<\/span><\/h2>\r\n<span>[h5p id=\"77\"]<\/span>\r\n\r\n<span>[h5p id=\"78\"]<\/span>\r\n\r\n<\/div>","rendered":"<p><span style=\"color: #000000\">Assessments of the integumentary system may be uncomfortable, embarrassing, or evoke anxiety for the client. It is possible that the client has been avoiding consultation with a healthcare provider for some time and the condition has advanced. The client may be fearful of the outcome of the assessment, for example, with concerns of malignancy. <\/span><\/p>\n<p><span style=\"color: #000000\">During your assessment, try to:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Attend to their concerns and ensure open communication with the client while commending them for seeking care. Ignoring their stress or delayed consultation may reinforce that they should be fearful of their integumentary concern and this could affect their follow-up care.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Show unconditional positive regard for the client and empathy for their situation; this will help you collaborate with the client.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Be clear about next steps and what the client can anticipate during their consultation; this is imperative to a positive therapeutic approach.\u00a0<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000\">Start the conversation with \u201cwhat brings you here today\u201d and pay attention to their response. The client may identify a particular symptom such as itchiness, swelling, or a lump. Their responses should prompt further questions to help you better understand the underlying issue. A systematic way to approach this line of questioning is to use the <a href=\"https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/chapter\/the-pqrstu-assessment\/\" target=\"_blank\" rel=\"noopener\">PQRSTU<\/a> mnemonic, which can help ensure you have covered the important basics.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">As a critical thinker, you should also consider what else may warrant further inquiry beyond the PQRSTU mnemonic. For example, you might ask about previous environmental exposures, medications (including name, dose, frequency, reason it was prescribed, how long they have been taking the medication), herbal remedies, supplements, allergies, non-prescribed substance use, and exposure to <button class=\"glossary-term\" aria-describedby=\"1096-1448\">contagions<\/button>.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">You can motivate the client to make lifestyle changes by ending the conversation with collaborative dialogue around health promotion strategies such as appropriate sunscreen application, regularly cleaning nail tools, and education about vitamins. Depending on the context, you might engage in this kind of discussion during the subjective assessment or after the objective assessment. A section on \u201cHealth Promotion Considerations and Interventions\u201d is provided later in this chapter.<\/span><\/p>\n<div class=\"textbox shaded\">\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity\u00a0<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">Western health assessment textbooks have been criticized for reinforcing a Euro-centric view of disease by largely focusing on ailments of white skin, and overlooking variations of black and brown skin. This kind of <strong>systemic racism<\/strong> can narrow the scope of knowledge of healthcare providers and can result in conditions being missed, further marginalizing racialized populations. Inclusive care requires more attention to black and brown skin variations, and this textbook is a first step. You can also access supplementary tools such as <a href=\"https:\/\/www.blackandbrownskin.co.uk\/mindthegap\" target=\"_blank\" rel=\"noopener\">Mind the Gap<\/a>\u00a0to help you recognize clinical signs in black and brown skin.\u00a0<\/span><\/p>\n<\/div>\n<p><span style=\"color: #000000\">Depending on the reason for seeking care, the healthcare context, and the nature of the client\u2019s visit, you may choose to start with screening questions about general health or enter immediately into a focused examination of the integument. Use your clinical judgement about the appropriateness of your questions and try to use a balanced approach between your own workload, the timing of visit, the urgency of the issue, and the nature of the healthcare setting. <strong>Table 3<\/strong> provides some examples of symptoms, questions, and clinical tips.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Table 3:<\/strong> Common symptoms, questions, and clinical tips.<\/span><\/p>\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr class=\"shaded\">\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><strong>Symptoms<\/strong><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><strong>Questions<\/strong><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><strong>Clinical Tips<\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Pruritus<\/strong> refers to itching. It is sometimes associated with a rash.<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking: Do you currently or have you recently had any itching on your skin?<\/span><\/p>\n<p><span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Do you have the itching now?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span><\/p>\n<p><span style=\"color: #000000\">Region: Where is it?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Radiation: Has it spread anywhere else?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Understanding: Do you know what has caused it?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Timing: When did it start? What were you doing when it started? Is it constant or intermittent? How long does it last?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Provocative: What makes the itchiness worse?<\/span><\/p>\n<p><span style=\"color: #000000\">Palliative: What relieves it?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality: How would you describe the itchiness?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Quantity: How bad is it?<\/span><\/p>\n<p><span style=\"color: #000000\">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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Treatment: Have you treated it with anything? Did it help?<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">Assess whether the itching is localized or generalized.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Localized pruritus<\/strong> 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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Generalized pruritus<\/strong> 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).\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Also assess for secondary infections, which can occur when there is breakdown of the skin from repeated scratching.\u00a0<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Skin rashes<\/strong> can vary in qualities such as colour, texture, and pattern.<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking: Do you currently or have you recently had any rashes on your skin?<\/span><\/p>\n<p><span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Do you have any rashes now?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span><\/p>\n<p><span style=\"color: #000000\">Region: Where is it?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Radiation: Has it spread?<\/span><\/p>\n<p><span style=\"color: #000000\">Understand: Do you know what is causing it?<\/span><\/p>\n<p><span style=\"color: #000000\">Timing: When did it start? What were you doing when it started?<\/span><\/p>\n<p><span style=\"color: #000000\">Provocative: What brings on the rash?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Palliative: What makes it better?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality: How would you describe the rash?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Quantity: How bad is it?<\/span><\/p>\n<p><span style=\"color: #000000\">Treatment: Have you treated it with anything? Did it help?<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">Identifying skin rashes involves many considerations. With experience, you will begin to recognize common rashes and their morphology.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Consider whether the rash is <strong>acute<\/strong> (new onset) or <strong>chronic<\/strong> (lasting more than 6 weeks) as this will give you important information about the timeline and possible exposures or underlying conditions.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">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.\u00a0<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Nevi<\/strong> are moles.<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking: Have you noticed any abnormal looking moles, new moles, or changes in your moles?<\/span><\/p>\n<p><span style=\"color: #000000\">If the answer is affirmative, ask the client to describe the change. Additional <strong>probes<\/strong> if the response is affirmative:<\/span><\/p>\n<p><span style=\"color: #000000\">Region: Where is it located?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality: What does it look like? Has it changed in colour? Have you observed it growing in size?<\/span><\/p>\n<p><span style=\"color: #000000\">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?\u00a0<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">Most moles are <strong>benign<\/strong> (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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">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 (<strong>to be discussed in the Objective assessment section<\/strong>).<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Skin discolouration<\/strong> and<strong> skin<\/strong> <strong>temperature changes<\/strong>.\u00a0<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking: Have you noticed any changes in skin colour or skin temperature on any areas of your body?<\/span><\/p>\n<p><span style=\"color: #000000\">If the answer is affirmative, ask the client to describe the change. Additional <strong>probes<\/strong> if the response is affirmative:<\/span><\/p>\n<p><span style=\"color: #000000\">Region\/radiation: Where is it located? Have you noticed it anywhere else?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality\/quantity: Can you describe what it looks like or feels like? How bad is it?<\/span><\/p>\n<p><span style=\"color: #000000\">Provocative\/palliative: What makes it better? What makes it worse?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">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?<\/span><\/p>\n<p><span style=\"color: #000000\">Understanding: Do you know what is causing it?<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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 &#8211; 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.\u00a0<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-288x300.png\" alt=\"A dark line down the centre of the abdomen.\" width=\"194\" height=\"202\" class=\"alignnone wp-image-1094\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-288x300.png 288w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-985x1024.png 985w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-768x799.png 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-65x68.png 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-225x234.png 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered-350x364.png 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2022\/12\/Linea_nigra_line_2016-altered.png 1152w\" sizes=\"auto, (max-width: 194px) 100vw, 194px\" \/><\/p>\n<p><span style=\"color: #000000\">Linea nigra.<\/span><\/p>\n<p><span style=\"color: #000000\">(Attribution: Photo by Warinhari &#8211; Own work, CC BY-SA 4.0,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=47136053\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=47136053<\/a><span style=\"color: #000000\">)<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks-300x192.png\" alt=\"White, silver coloured lines on the abdomen.\" width=\"195\" height=\"125\" class=\"alignnone wp-image-1095\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks-300x192.png 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks-65x42.png 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks-225x144.png 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks-350x224.png 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Dr.PlacikAbdominoplasty-Stretch-marks.png 768w\" sizes=\"auto, (max-width: 195px) 100vw, 195px\" \/><\/p>\n<p><span style=\"color: #000000\">Striae.<\/span><\/p>\n<p><span style=\"color: #000000\">(Attribution: Photo by Emilymiller123 &#8211; Otto J. Placik, M.D., CC BY-SA 3.0,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=6972012\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=6972012<\/a><span style=\"color: #000000\">, cropped for OER)<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Ulcers<\/strong> are open sores on the skin.<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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?<\/span><\/p>\n<p><span style=\"color: #000000\">Additional <strong>probes<\/strong> if the response is affirmative:<\/span><\/p>\n<p><span style=\"color: #000000\">Region\/radiation: Where are they located? Have you noticed them anywhere else?<\/span><\/p>\n<p><span style=\"color: #000000\">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?<\/span><\/p>\n<p><span style=\"color: #000000\">Timing: When did the sore begin? Do you know how it developed<\/span><\/p>\n<p><span style=\"color: #000000\">Treatment: Have you treated it with anything<\/span><\/p>\n<p><span style=\"color: #000000\">Understanding: Do you know what is causing it?\u00a0<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">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).<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Nail changes<\/strong> can include changes in consistency, texture, and colour.<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking: Have you noticed any changes in your nails on your hands or feet?<\/span><\/p>\n<p><span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Tell me about the changes?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span><\/p>\n<p><span style=\"color: #000000\">Region: What nails are involved?<\/span><\/p>\n<p><span style=\"color: #000000\">Radiation: Have you noticed it spreading?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality: How would you describe it?<\/span><\/p>\n<p><span style=\"color: #000000\">Quantity: How bad is it?<\/span><\/p>\n<p><span style=\"color: #000000\">Provocative: Is there anything that makes it worse<\/span><\/p>\n<p><span style=\"color: #000000\">Palliative: Is there anything that makes it better?<\/span><\/p>\n<p><span style=\"color: #000000\">Timing: When did you notice the change beginning? Is it constant or intermittent? If intermittent, how long does it last?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Understanding: Do you know what is causing the change?<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Colour changes<\/strong> can include white lines, darkening of the nail, or cyanosis.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Texture changes<\/strong> to the nail can include a thickening of the nail, as with fungal infections. A thickening and overgrowth that looks like a ram\u2019s 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\u2019s line; it is typically a sign that the nail has stopped or slowed in growth.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Changes to the <strong>shape of the nail<\/strong> 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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Lifting of the nail<\/strong> can be the result of a fungal infection or trauma from cleaning or manicuring the nails. <strong>Onycholysis<\/strong> refers to a nail separating from the underlying tissue. <strong>Ingrown toenail<\/strong> refers to a nail growing into tissue; this causes pain, inflammation, and swelling, and can lead to infection.<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Alopecia<\/strong> refers to hair loss, which can include thinning of the hair or complete loss of the hair on any part of the body.\u00a0<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking: Have you noticed any hair loss on your body or head?<\/span><\/p>\n<p><span style=\"color: #000000\">If the client\u2019s response is affirmative, ask: Tell me about it?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Additional <strong>probes<\/strong> may include:<\/span><\/p>\n<p><span style=\"color: #000000\">Region: Where have you noticed it?<\/span><\/p>\n<p><span style=\"color: #000000\">Region: Has it spread anywhere?<\/span><\/p>\n<p><span style=\"color: #000000\">Timing: When did it start? What was going on in your life when it began? Was it abrupt or did it come on slowly<\/span><\/p>\n<p><span style=\"color: #000000\">Understanding: Do you know what might be causing it<\/span><\/p>\n<p><span style=\"color: #000000\">Provocative: What brings on the hair loss?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Palliative: Does anything make it better?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality: How would you describe the hair loss?\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Quantity: How bad is it?<\/span><\/p>\n<p><span style=\"color: #000000\">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?<\/span><\/p>\n<p><span style=\"color: #000000\">Treatment: Have you treated it with anything? Has it worked?<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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\u20136 months after the event.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Hair loss can be damaging to the client\u2019s self-concept so it is important to treat them with empathy.\u00a0<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Other integumentary-related<\/strong> symptoms can include xerosis (dry skin), seborrhea (oily skin), bruising, fatigue and fever.\u00a0<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">Always ask one question at a time.\u00a0You might start by asking:<\/span><\/p>\n<p><span style=\"color: #000000\">Have you experienced any body fatigue? (Or fever, bruising, dry or oily skin?)<\/span><\/p>\n<p><span style=\"color: #000000\">Use variations of the PQRSTU mnemonic to assess symptoms further if the client\u2019s response is affirmative.<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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.<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 59.3184%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Personal<\/strong> and <strong>family history<\/strong> of integumentary conditions and diseases.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Some common issues associated with the integumentary system include eczema and psoriasis.<\/span><\/td>\n<td style=\"vertical-align: top;width: 42.6861%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">You might start by asking:\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">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?<\/span><\/p>\n<p><span style=\"color: #000000\">If the client\u2019s response is affirmative, begin with an open-ended probe: Tell me about the condition\/disorder\/disease?<\/span><\/p>\n<p><span style=\"color: #000000\">If the client has a personal history, <strong>probing questions<\/strong> might include:<\/span><\/p>\n<p><span style=\"color: #000000\">Timing: When did you begin experiencing symptoms related to this condition? When were you diagnosed? Are the symptoms constant or intermittent?<\/span><\/p>\n<p><span style=\"color: #000000\">Quality\/quantity: How does it affect you? What symptoms do you have? How bad are the symptoms<\/span><\/p>\n<p><span style=\"color: #000000\">Treatment: How is it treated? Have you had any surgeries? Do you take medication?<\/span><\/p>\n<p><span style=\"color: #000000\">Provocative\/palliative: Does anything make it worse? Does anything make it better?<\/span><\/p>\n<p><span style=\"color: #000000\">Understanding: What personal or family history do you think is important for me to understand?\u00a0<\/span><\/td>\n<td style=\"vertical-align: top;width: 1.07643%\">&nbsp;<\/p>\n<p><span style=\"color: #000000\">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\u2019s 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\u2019s disease, psoriasis, and rheumatoid arthritis. Common symptoms related to auto-immune disease include fatigue, joint pain and inflammation, digestive issues, and swollen lymph nodes.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">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.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Family history can provide some insights into predisposition to other conditions related to the integumental system, such as <button class=\"glossary-term\" aria-describedby=\"1096-1446\">rosacea<\/button>.\u00a0<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div style=\"text-align: left;\">\n<p>&nbsp;<\/p>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p><span style=\"color: #000000\">Personal protective equipment (PPE) like gloves may be necessary for skin variations that expel bodily fluids like blood or pus. Some lesions can expel with pressure when punctured and a face shield may be necessary.\u00a0<\/span><\/p>\n<p>Urticaria (hives) are itchy patches and bumps that are sometime raised and look swollen. They may look lighter or darker than one\u2019s normal skin colour on clients with darker tones and they look red and dark pink on clients with lighter skin tones and sometimes with white centres. They are sometimes caused by an allergic reaction to food, medications, or a bug bite. Although they often disappear with no treatment or an antihistamine, in rare cases they could be associated with a severe allergic reaction (anaphylaxis) including symptoms of dyspnea (difficulty breathing), wheezing, tightness or swelling of the throat. Anaphylaxis is a life-threatening condition and needs to be reported and treated immediately; administration of epinephrine is a priority if anaphylaxis is suspected.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.atlasdermatologico.com.br\/img?imageId=7779\" width=\"445\" height=\"396\" class=\"alignnone\" alt=\"Patches and bumps on person's back.\" \/> <img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.atlasdermatologico.com.br\/img?imageId=7780\" width=\"444\" height=\"330\" class=\"alignnone\" alt=\"Raised swollen patches on person's skin.\" \/><\/p>\n<p>Urticaria: Image free to use for non-commercial purposes, from: https:\/\/www.atlasdermatologico.com.br\/index.jsf<\/p>\n<\/div>\n<\/div>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Knowledge Bites<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p><span style=\"color: #000000\">Certain medications can cause photoreactions, which are skin reactions caused by exposure to sunlight. Consumption of certain medications can lead to photosensitivity (sensitivity to sun exposure), photo-allergy (inflammation\/allergic reaction after exposure to sun), and phototoxicity (hazardous sensitivity to sunlight that causes damage to tissue). Medications with these possible side effects include antibiotics, antihistamines, psychiatric agents, and cardiovascular drugs, as well as some topical medications.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Vitamins and some herbal remedies can also cause photoreactions and other integumentary responses. For example, niacin (vitamin B3) toxicity can cause flushing (reddened skin, itching, tingling). Excess vitamin A can cause itching, scaling, cheilitis (dry chapped lips), and even hair loss. Excess vitamin B6 can cause skin eruptions, typically after sun exposure. <button class=\"glossary-term\" aria-describedby=\"1096-1480\">St. John\u2019s wort<\/button> can cause hives and\/or other skin reactions. Other screening questions pertinent to a subjective assessment relate to personal care routines, sun exposure, and exposure to other irritants.<\/span><\/p>\n<\/div>\n<\/div>\n<div class=\"textbox shaded\">\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">Malnutrition is associated with social determinants of health such as socioeconomic status, as well as many conditions. For example, it can be associated with alcoholism, either because of inadequate dietary intake accompanied by overconsumption of alcohol that does not contain nutrients or due to malabsorption from gastrointestinal conditions secondary to alcoholism. Persons living with alcoholism often have deficiencies in vitamin A, B1, B2, B6, C, E, and niacin, as well as other nutrient depletions like magnesium, potassium, and zinc. Chronic alcoholism can lead to skin changes related to liver disease, such as jaundice (yellowing of skin and sclera) due to bilirubin build up, hyperpigmentation, and generalized pruritus. Recognizing the signs of alcoholism is an important first step in seeking treatment. Family members are often the first to identify a problem. Always build a therapeutic relationship with the client, including unconditional positive regard; this will help establish trust and connect the client with appropriate supports.\u00a0<\/span><\/p>\n<\/div>\n<h2><span>Activity: Check Your Understanding<\/span><\/h2>\n<p><span><\/p>\n<div id=\"h5p-77\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-77\" class=\"h5p-iframe\" data-content-id=\"77\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Integumentary - Subjective data\"><\/iframe><\/div>\n<\/div>\n<p><\/span><\/p>\n<p><span><\/p>\n<div id=\"h5p-78\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-78\" class=\"h5p-iframe\" data-content-id=\"78\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Subj assessment\"><\/iframe><\/div>\n<\/div>\n<p><\/span><\/p>\n<\/div>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"1096-1448\" hidden><p>are microorganisms transmitted by close contact (direct or indirect).<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"1096-1446\" hidden><p>is a condition where the facial cheeks and nose have a flushed appearance from enlarged facial blood vessels.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"1096-1480\" hidden><p>is a plant, commonly used as a dietary supplement\/herbal remedy.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":4,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-nc"},"chapter-type":[],"contributor":[85],"license":[56],"class_list":["post-1096","chapter","type-chapter","status-publish","hentry","contributor-january-2023","license-cc-by-nc"],"part":1074,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1096","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":5,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1096\/revisions"}],"predecessor-version":[{"id":3851,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1096\/revisions\/3851"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/1074"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/1096\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=1096"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=1096"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=1096"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=1096"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}