Assessing Skin, Hair, and Nails

Assessing Skin, Hair, & Nails

• Physical assessment techniques are utilized to assess the skin, hair, and nails
• The goal is to differentiate between normal and abnormal findings
• Data from interviews and physical assessments are analyzed to formulate nursing diagnoses, collaborative problems, or referrals

Integumentary System

• The system includes skin, hair, and nails; each structure has specialized functions
• Sebaceous and sweat glands originate within the skin and have vital functions

Skin

• It functions as the largest organ
• The skin acts as a barrier protecting underlying tissues from microorganisms, physical trauma, ultraviolet radiation, and dehydration
• Also gives a unique appearance to individuals
• It is thicker on palms and soles

Skin Functions

• Temperature maintenance,
• Fluid and electrolyte balance
• Absorption
• Excretion
• Sensation
• Immunity
• Vitamin D synthesis

Skin Structure

• It connects to mucous membranes at body orifices seamlessly
• The outer visible layer contains keratin, a protective protein causing tissue to become callous
• The outermost layer consists of dead keratinized cells
• The innermost layer is the only one undergoing cell division
• Melanin and keratin are produced by cells in the skin

Epidermis

• It's the outermost layer protecting the body from harm and keeps the body hydrated
• New skin cells are produces and it contains melanin, determining skin color
• Composed of four layers, the "Stratum Corneum" and "Stratum Germinativum"

Dermis

• It's composed of proteins and mucopolysaccharides, forming a thick, gelatinous material
• Supports nerve tissue, blood vessels, sweat and sebum glands, and hair follicles
• Collagen, elastic fibers, nerve endings, and lymph vessels are included

Subcutaneous Tissue

• Loose connective tissue includes fat cells, blood vessels, nerves, sweat glands, and hair follicles
• It serves as a storage site for fat, serving as an energy reserve
• Provides insulation to conserve body heat
• Acts as a cushion, offering protection to bones and internal organs.

Objective Data Collection and Physical Assessments

• Inspect skin color, temperature, moisture, and texture
• Check skin integrity
• Be alert for skin lesions
• Evaluate hair condition, loss, or unusual growth
• Note nail bed condition and capillary refill

General Skin Color Assessment: Normal vs. Abnormal

• Normal skin is evenly colored without unusual or prominent discolorations
• Abnormal skin shows pallor, cyanosis, jaundice, or erythema.

Pallor

• Loss of color is seen in arterial insufficiency, decreased blood supply, and anemia

Cyanosis

• It appears blue especially in the perioral, nail bed, and conjunctival areas
• Appears blue, dull, lifeless in dark-skinned individuals
• Central cyanosis results from cardiopulmonary problems
• Peripheral cyanosis may be a local problem resulting from vasoconstriction.

Jaundice

• Yellow skin tones range from pale to pumpkin
• Evident in the sclera, oral mucosa, palms, and soles

Erythema

• Redness of the skin or mucous membranes is caused by hyperemia (increased blood flow) in superficial capillaries
• It occurs with any skin injury, infection, or inflammation

Acanthosis Nigricans

• Velvety darkening of the skin in body folds, creases, especially the neck, groin, and axilla.

Normal Variations in Skin Color

• Suntanned areas, freckles, or vitiligo are common
• Variations are due to different amounts of melanin

Abnormal Color Variations

• Rashes and butterfly rashes (malar rash across the nose and cheeks) are characteristic of Systemic Lupus Erythematosus

Primary Skin Lesions

• Papule: small, raised, solid mass, less than 0.5cm (e.g., warts, nevi)
• Plaque: larger raised area, more than 0.5 cm (e.g., psoriasis)
• Vesicle: small, fluid-filled blister, less than 0.5 cm (e.g., poison ivy)
• Bulla: larger fluid-filled blister, more than 0.5 cm
• Cyst: closed sac-like structure containing fluid, pus, or other material.
• Nodule: palpable, solid, rounded mass, larger than a papule.
• Tumor: swelling or abnormal growth of tissue, greater than 1 to 2cm.
• Wheal: raised, red, and itchy area, often transient (e.g., hives, insect bites)
• Pustule: small, elevated lesion filled with pus (e.g., acne)

Secondary Skin Lesions

• Erosions are shallow, superficial defects involving the loss of topmost skin layers
• Scabs
• Lichenification includes thickening and hardening of the skin, often with exaggerated markings
• Excoriations include superficial wounds or abrasions
• Atrophy involves a decrease in size, thickness, and functionality of skin or underlying tissues
• Ulcers are a deeper loss of skin that extends into the dermis or subcutaneous tissue

Vascular Lesions

• Include petechiae, ecchymosis, capillary hemangioma, cherry angioma, and telangiectasia

Skin Integrity Assessment

• Normal skin is intact without reddened areas
• Pay special attention to pressure point areas

Braden Scale

• The scale is used to predict pressure sore risk.

PUSH Tool

• The tool documents the degree of skin breakdown for comparison of healing/deterioration over time

Pressure Ulcer Stages

• Stage 1: Intact skin with non-blanchable redness
• Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed
• Stage 3: Full-thickness loss with subcutaneous fat visible
• Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle

Characteristics of Skin Lesions: Normal vs. Abnormal

• Normal skin is smooth, without lesions
• Stretch marks (striae), healed scars, freckles, moles, or birthmarks are common findings.
• Lesions may indicate local or systemic problems; note symmetry, borders, shape, color, diameter, and change in the lesion over time
• Lesions can be primary (initial alteration) or secondary (arising from changes in primary lesions)

Skin Abnormalities

• Herpes simplex presents as painful blisters on or around the mouth or genital area
• Intertigo is characterized by redness, itching, and maceration in areas like the groin, armpits, or under the breasts
• Pityriasis rosea features a rash that resembles tree branches
• Seborrhea is a chronic inflammatory skin condition affecting areas rich in oil glands
• Tinea capitis, also known as scalp ringworm, a fungal infection of the scalp and hair follicles
• Rosacea is a skin condition that includes redness, visible blood vessels, bumps, and swelling

ABCDEs of Melanoma

• Asymmetry: One half unlike the other half
• Border: Irregular, scalloped, or poorly defined
• Color: Varied shades of tan, brown, or black
• Diameter: Typically greater than 6mm when diagnosed, but can be smaller
• Evolving: A mole that looks different from the rest or is changing in size, shape, or color

Skin Texture

• Normal skin is smooth and even; use the palmar surface of your three middle fingers to palpate
• Rough, dry, flaky skin is seen in hypothyroidism

Skin Thickness

• Normal skin is thin, but calluses are common on areas exposed to pressure
• Very thin skin may be seen in arterial insufficiency
• Using steroid therapy may contribute

Skin Moisture

• Skin surfaces vary in being most or dry
• Elderly skin may feel drier because sebum production decreases
• Increased moisture (diaphoresis/profuse sweating) may occur in hyperthyroidism
• Decreased moisture occurs with dehydration or hypothyroidism.

Skin Temperature

• Normal skin is warm
• Dorsal surfaces of the hand can measure skin temperature
• Cold skin may accompany shock or hypotension
• Cool skin may accompany arterial disease
• Very warm skin may indicate a febrile state or hyperthyroidism

Skin Mobility and Turgor

• Normal skin is mobile, with elasticity, and returns to its original shape quickly
• Decreased turgor (recoil more than 2 seconds) suggests dehydration
• More than 3 seconds is described as tenting

Palpate to Detect Edema

• Normal skin rebounds and does not remain indented when pressure is released
• Indentations on the skin may vary from slight to great and may be in one area or all over the body

Normal Nail

• Has a convex shape with a nail plate angle of about 160 degrees

Schamroth Window Test

• Determines the presence of clubbing, viewing the nail bed

Deviations from Normal Nails

• Bluish/purplish tint or pallor/pale fingernails may be deviations from normal, where the finger nails should be vascular and pink
• Hangnails and paronychia
• Yellow nails associated with cigarette smoking, fungal infections, and psoriasis
• Distal band of reddish-pink-brown in Lindsay's nails seen in renal disease and hypoalbuminemia
• White nails caused by trauma, cardiovascular, liver, or renal disease
• Blue (cyanotic) nails with clubbing can be indicative of peripheral disease or hypoxia.
• Koilonychia (spoon nails)

Learn how to use physical assessment techniques to assess the skin, hair, and nails. Differentiate between normal and abnormal findings. This lesson covers the integumentary system, skin structure, and skin functions such as temperature maintenance, fluid and electrolyte balance, and immunity.