Physical Examination of the Integumentary System

Primary Lesions

• Macule: A flat, non-palpable change in color $< 1$ cm (e.g., a flat mole). If it is $> 1$ cm, it is called a patch.
• Papule: A solid, raised lesion with distinct borders $< 0.5$ cm (e.g., a wart). If it is $> 0.5$ cm, it is called a plaque.
• Nodule: A deeper, solid mass (0.5–2 cm) that extends into the dermis.
• Tumor: A larger solid mass that may extend through subcutaneous tissue.
• Vesicle: A circumscribed, raised lesion filled with clear serous fluid $< 0.5$ cm (e.g., chicken pox). If $> 0.5$ cm, it is a bulla.
• Pustule: An elevated lesion containing purulent fluid (pus).
• Wheal: An irregularly shaped area of edema caused by serous fluid in the dermis (e.g., hives).
• Cyst: An encapsulated, fluid-filled or semisolid mass.

Palpation of the Skin

Palpation is essential for determining the skin's texture (smooth vs. rough), temperature (using the back of the hand), and turgor. To test turgor, grasp a fold of skin on the forearm or sternum and release it. A quick recoil indicates good hydration, while a slow recoil suggests dehydration.

Clinicians must also assess for edema (swelling). This is performed by applying pressure to the skin over a bony prominence like the tibia. Pitting edema is graded on a scale:

• 1+: Slight pitting (2mm).
• 2+: Deeper pit (4mm).
• 3+: Deep pit (6mm); extremity appears enlarged.
• 4+: Very deep pit (8mm); extremity is extremely distorted.

Hair and Scalp Assessment

Hair is assessed for color, quantity, distribution, thickness, and texture. Two main types of hair are noted: vellus hair (short, fine, pale) and terminal hair (coarse, dark, visible on the scalp and axillae).

Key findings during hair assessment include:

• Hirsutism: Excessive hair growth on areas like the face or chin.
• Alopecia: Hair loss.
• Pediculosis: Infestation by parasites (lice), which often causes pruritus (itching).

Nail Assessment

Nail inspection focuses on the shape of the nailbed and the circulation to the extremities. A normal nailbed should show a "diamond-shaped window" when viewed from a 160-degree angle between the nail and the nail plate.

Clubbing and Capillary Refill

• Clubbing: If the angle is higher than 160 degrees, it indicates clubbing, which can be associated with chronic respiratory or cardiac issues.
• Capillary Refill: Press the nailbed for 1 second and release. A "brisk" return of color in less than 2–3 seconds is normal. A return of $> 2\text{--}3$ seconds is considered slow or sluggish, potentially indicating cardiac or respiratory impairment.

Warning: Always inspect skin lesions that are actively growing, changing shape, bleeding, or itching, as these may be signs of skin malignancies such as Basal cell carcinoma, Squamous cell carcinoma, or Melanoma.

Documentation and Completion

Once the physical examination is complete, the nurse must allow the patient time to dress and ensure the exam area is returned to its original condition. All findings must be recorded in the Electronic Health Record (EHR) promptly using appropriate nursing terminology. Any serious abnormalities or questionable findings must be reported to the healthcare provider immediately.