6.4 Subjective Assessment
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 health care 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.
During your assessment, try to:
- 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.
- Show unconditional positive regard for the client and empathy for their situation; this will help you collaborate with the client.
- Be clear about next steps and what the client can anticipate during their consultation; this is imperative to a positive therapeutic approach.
Start the conversation with “what brings you here today” 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 PQRSTU mnemonic, which can help ensure you have covered the important basics.
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 contagions.
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 “Health Promotion Considerations and Interventions” is provided later in this chapter.
Contextualizing Inclusivity
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 Mind the Gap to help you recognize clinical signs in black and brown skin.
Depending on the reason for seeking care, the health care context, and the nature of the client’s 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 judgment about the appropriateness of your questions and try to use a balanced approach between your own workload, the timing of the visit, the urgency of the issue, and the nature of the health care setting. Table 6.3 provides guidance on subjective assessment with some examples of symptoms, questions, and clinical tips.
| Symptoms | Questions | Clinical Tips |
| 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 itchiness 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 color, 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, and 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 color? 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 discoloration and skin temperature changes. | You might start by asking: Have you noticed any changes in skin color 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 color (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 color 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 (these conditions will be discussed further in a later chapter). |
| Nail changes can include changes in consistency, texture, and color. | 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.
Color 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 center 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 labor/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, or 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 family 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 immunocompromised) can decrease the body’s defenses 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, Graves’ 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 behavioral 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 integumentary system, such as rosacea. |
Priorities of Care
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.
Urticaria (hives) are itchy patches and bumps that are sometime raised and look swollen. They may look lighter or darker than one’s normal skin color on clients with darker tones and they look red and dark pink with white centers on clients with lighter skin tones. 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, or 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.
Urticaria: Images from: https://www.atlasdermatologico.com.br/index.jsf
Knowledge Bites
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), photoallergy (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.
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. St. John’s wort 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.
Contextualizing Inclusivity
Be aware of and respectful toward different cultural practices related to skin care. These practices can vary widely and may include the use of specific oils, lotions, or cleansing routines, as well as traditional treatments that may affect the skin’s appearance or texture. Henna, used in many cultures for body art, especially in South Asian and Middle Eastern communities, stains the skin and should not be confused with a skin condition.
