NUR111 Skin, Nail, Hair Assessment

Skin, Nail, Hair Assessment Overview

• This lecture is part of the NUR111-Health Assessment course
• Subjective and objective data collection are part of the assessment
• Included are techniques and findings for inspection and palpation
• It is important to document normal subjective and objective findings

Subjective Data Collection

• The first step is to assess history and risks
• Start with family history questions
• Inquire about first-degree relatives with melanoma
• Ask who had the problem, and if relatives have multiple dark, irregular moles
• For past history, ask about skin self-exams and clinical exams
• Determine any prior pigmented skin lesions, asking about the number, location, and changes
• Screen for any severe sunburns, especially during youth period
• Check on sun sensitivity
• Screen for previous instances of skin cancer along with when and where it occurred & treatment.
• Confirm if the patient had an organ transplant, HIV/AIDS, chemotherapy, or radiation therapy

Medications and Lifestyle Considerations

• Inquire about current medications
• Ask about allergies regarding medications, latex, nuts, bees, and other items
• Ask what the reaction was
• Confirm if the patient is allergic to sunscreen
• Discuss lifestyle, occupational history, and personal behaviors
• Ask about occupation and hobbies
• Determine exposure to excessive sunlight or other sources of radiation
• Inquire about sun exposure protection
• Assess risk for skin breakdown
• Confirm if any history of diabetes mellitus, peripheral vascular disease, or known sensory loss

Objective Data Collection

• Necessary equipment includes:
  • Examination gown
  • Tape measure
  • Adequate light source
  • Magnifying glass

Inspection Techniques and Normal Findings

• Inspect all body areas, starting from the head and progressing to the feet
• Part the hair to visualize the scalp
• Ensure the soles of the feet are assessed, separating the toes
• General skin color should be noted
• Consistent body pigmentation is a normal finding
• Dark-skinned individuals may have hypopigmented palms and soles

Lesion Observations

• Inspect for lesions
• Identify morphology, configuration, and distribution patterns if lesions observed
• Also note size and exact location, identify benign lesions which may indicate the following:
  • freckles
  • birthmarks
  • skin tags
  • moles
  • cherry angiomas

Lesion Configurations

• Annular lesions are ring-like
• Arciform lesions are half-ring shaped
• Linear lesions are line-shaped
• Polymorphous lesions consist of several different shapes
• Serpiginous lesions are curving, snake-like
• Nummular/discoid lesions are coin-shaped
• Umbilicated lesions have a central depression
• Punctuate lesions have small, marked points or dots
• Filiform lesions have papilla-like or finger-like projections

Lesion Distribution Patterns

• Asymmetric distribution is solely on one side of the body
• Diffuse distribution occurs widely across the affected area without any pattern
• Localized distribution is located at a distinct area
• Symmetric distribution is equally on both sides of the body

Primary and Secondary Lesions

• Primary skin lesions are present at the onset of a disease
• Primary lesions develop as a direct result of the disease process
• Secondary skin lesions result from changes over time caused by the disease progression, manipulation, or treatment
• Secondary lesions evolve from primary lesions or develop as a consequence of patient activities

Types of Skin Lesions

• Macule
• Papule
• Patch
• Plaque
• Nodule
• Vesicle
• Bulla
• Ulcer
• Crust
• Atrophy
• Scar
• Erosion
• Fissure

Inspection: Additional Techniques

• Identify any infections, using infection-control principles if infection suspected
• Note any inflammatory lesions and observe for growths, tumors, or other lesions
• If wounds or incisions are present, note shape, length, width, and depth and if its tunneling.
• Describe wounds related to trauma
• Assess status of blood supply and note any bleeding or ecchymosis (bruising)
• Identify risk for skin breakdown

Wound Assessment

• Classify the wound as partial or full-thickness.
• If a pressure ulcer is present, identify the stage
• Document size (in depth and diameter), margins, condition of surrounding tissues
• Check for drainage, odor, or necrotic tissue
• Describe color and texture of the tissue
• Identify amount, color, consistency, and odor of exudate
• Assess for non-pressure ulcers, and note characteristics

Fingernails and Toenails

• Inspect each fingernail and toenail
• Assess for color, thickness, and consistency
• Nails should be smooth, translucent, and consistent in color and thickness
• Longitudinal ridging is common in aging patients
• Longitudinal pigmentation in dark-skinned patients is a normal variant
• Have patient place the fingernails of both index fingers together to assess the nail angle, a diamond-shaped opening between the fingernails indicates a nail angle of at least 160 degrees

Hair Inspection

• Inspect the condition of the hair shaft
• Inspect the hair while noting:
  • Color
  • Consistency
  • Distribution
  • Areas of hair loss
• The hair and scalp should be equally and symmetrically distributed across the scalp Areas of decreased or absent hair should be evaluated
• Visualizing the skin on the scalp allows notating any lesions or color changes
• The scalp should match the body's color.

Palpation Techniques

• Using the dorsal surface of the hands, assess skin temperature
• The palmar surface of the fingers and hands should be used to assess the skin moisture and texture
• Skin temperature is consistently warm or cool and appropriate to the environment
• Moisture is consistently throughout, with evenly smooth skin texture
• Assess skin turgor by grasping a fold of the patient’s skin between fingers and pull up, then release the skin
• If there is appropriate fluid intake, then the skin should promptly recoil to its normal position

Palpation: Additional Techniques

• Assess for vascularity by applying direct pressure to the skin surface with the pads of fingers
• On releasing your finger, color should promptly return to normal
• Assess lesions by palpating the following:
  • Tenderness, mobility, and consistency
• Palpate each fingernail and toenail
• With fingernails, check if they are smooth, nontender, and firmly adherent to the nail bed
• The lateral and proximal nail folds should be nontender and nonswollen
• Grasp 10 to 12 hairs and gently pull to palpate the hair & typically only a few should be in your hand

Documentation

• When documenting normal subjective and objective findings indicate the following:
  • No noted pruritus of the skin
  • No lesions noted
  • Skin has no excessive dryness
  • Existing moles are not changing
  • Skin is evenly colored, smooth, soft and consistently warm
  • Skin has intact turgor
  • No suspicious lesions
  • Nails are smooth and translucent and lateral and proximal folds are normal
  • Hair is smooth in texture and is symmetrically distributed on the scalp
  • Has consistent coloration and hydration with no breakage or hair loss
  • The scalp and skin have consistent pigmentation