Evaluating The Bedbound Patient

People who are confined to bed, especially when they are emaciated, elderly, or neurologically impaired, are particularly susceptible to skin damage and ulceration. Pressure sores result when sustained compression obliterates arte-riolar and capillary blood flow to the skin. Sores may also result from the shearing forces created by bodily movements. When a person slides down in bed from a partially sitting position, for example, or is dragged rather than lifted up from a supine position, the movements may distort the soft tissues of the buttocks and close off the arteries and arterioles within. Friction and moisture further increase the risk.

Carotenemia

Dryness in hypothyroidism; oiliness in acne

Generalized warmth in fever, hyperthyroidism; coolness in hypothyroidism. Local warmth of inflammation or cellulitis

Roughness in hypothyroidism

Decreased mobility in edema, scleroderma; decreased turgor in dehydration

Many skin diseases have typical distributions. Acne affects the face, upper chest, and back; psoriasis, the knees and elbows (among other areas); and Candida infections, the intertriginous areas.

Vesicles in a unilateral dermatomal pattern are typical of herpes zoster.

See Table 4-1, Basic Types of Skin

Vascular and Purpuric Lesions of the Skin (p._); Table 4-4, Skin

Tumors (p._); and Table 4-5, Benign and Malignant Nevi (p._).

Assess every susceptible patient by carefully inspecting the skin that overlies the sacrum, buttocks, greater trochanters, knees, and heels. Roll the patient onto one side to see the sacrum and buttocks.

Local redness of the skin warns of impending necrosis, although some deep pressure sores develop without antecedent redness. Ulcers may be seen.

M Nails

Inspect and palpate the fingernails and toenails. Note their color and shape, and any lesions. Longitudinal bands of pigment may be seen in the nails of normal people who have darker skin.

See Table 4-7, Findings In or Near the Nails (pp. __-__).

H Hair

Inspect and palpate the hair. Note its quantity, distribution, and texture.

Alopecia refers to hair loss—diffuse, patchy, or total.

H Skin Lesions in Context

After familiarizing yourself with the basic types of lesions, review their ap-irances in Table 4-8 and in a well-illustrated textbook of dermatology. enever you see a skin lesion, look it up in such a text. The type of lesions, their location, and their distribution, together with other information from the history and the examination, should equip you well for this search and, in time, for arriving at specific dermatologic diagnoses.

Sparse hair in hypothyroidism; fine silky hair in hyperthyroidism

See Table 4-8, Skin Lesions in Context (pp. __-__).

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