Skin, Hair, and Nails Assessment: Key Considerations

• Nurses assess a patient's skin, hair, and nails as part of a comprehensive head-to-toe assessment
• These simple body parts can reveal a lot about a person's overall health

Key equipment for physical assessment

• Gloves
• Exam light
• Penlight
• Magnifying glass
• Centimeter ruler
• Wood lamp

Rationale for assessment practice:

• Conserves time and energy
• Promotes efficiency
• Maintains safety
• Ensures organization
• Fosters preparedness
• Upholds professionalism

Gathering Equipment and Explaining Procedure

• Patients have the right to make informed decisions about their healthcare via informed consent
• Understanding the procedure helps patients make an informed choice about whether to proceed

Procedure to follow

• Put patients in hospital gowns

Hygiene and Infection Control via hospital gowns

• Hospital gowns are designed to be disposable or easily washable
• This minimizes the risk of cross-contamination between patients
• Gowns also provide a barrier to prevent the spread of germs from clothing to the medical environment

Accessibility via hospital gowns

• Gowns allow for easy access to the areas of the body that need to be examined or treated
• Essential for procedures involving the chest, abdomen, or back

Safety via hospital gowns

• Gowns help prevent loose clothing from getting caught in medical equipment or interfering with a procedure

Comfort with hospital gowns

• While not the most comfortable garment, hospital gowns can provide a sense of privacy and modesty

Standardization with hospital gowns

• Using hospital gowns helps standardize the process

Integumentary system

• The largest organ consisting of 15-20% of total body mass

Integumentary system functions:

• Barrier to physical, chemical, and biological agents
• Homeostatic properties prevents water loss and regulates body temperature
• Sensory receptor to touch, pain and pleasure sensitivity
• Secretory functions convert precursor molecules to vitamin D, lubricants for hair and pheromones
• Excretory functions release sweat

Layers of the Skin

• Epidermis is the outermost layer, responsible for protecting the body from the environment
• The Dermis is the middle layer providing structural support containing blood vessels, nerves, hair follicles, and sweat glands.
• Responsible for giving skin its elasticity and strength
• Hypodermis is the innermost layer primarily composed of fat cells, acting as an insulator, protecting the body from temperature changes
• The hypodermis stores energy and helps hold the skin to underlying structures.

Function of the skin

• The skin is the body's largest organ
• Protection - It acts as a barrier against harmful substances, such as bacteria, viruses, and UV radiation.
• Regulation of body temperature - Helps regulate body temperature through sweating in blood vessel dilation and constriction
• Sensation - Contains numerous sensory receptors that allow touch, pressure, temperature, and pain sensation
• Excretion - Eliminates waste products from the body through sweat
• Vitamin D production - Exposure to sunlight leads to vitamin D production, essential for bone health

Skin assessment

• Assessing skin color is a crucial component of a comprehensive health assessment
• Variations in skin color can indicate a wide range of conditions from benign pigmentation variations to serious underlying illnesses
• Nurses must be adept at observing, documenting, and interpreting these variations

Skin assessment includes inspection for generalized color variations such as:

• Brownness
• Yellow
• Redness
• Pallor
• Cyanosis
• Jaundice
• Erythema
• Vitiligo

Skin assessment notes

• Assessment can happen at one time or as each aspect of the body is assessed.
• Assessment can also include olfaction
• Utilizes inspection, palpation.
• Olfaction assessment may include pungent body odor, hyperhidrosis and bromhidrosis.

Pallor (Skin)

• Check for inadequate circulating blood and or hemoglobin

Cyanosis (Skin)

• Check bluish-tinged areas occurring from reduction in tissue oxygenation; nail beds lips and buccal mucosa

Inspecting "Brownness" of Skin

• Melasma: Common pigmentation disorder that causes darker patches on the skin, primarily on the face.
• Melasma is triggered by hormonal changes, such as pregnancy, birth control or sun exposure
• Age Spots (Lentigo): Flat, brown spots caused by sun damage
• They tend to affect sun-exposed areas like hands, chest, face

Skin Problem

• Skin discoloration can be a sign of skin cancer, particularly melanoma
• Melanoma can appear as an atypical mole, often asymmetrical, multicolored, and large

Acanthosis Nigricans

• This condition causes dark velvety patches often in folds of the neck armpits and groin
• It can be a sign of underlying health issues like diabetes or insulin resistance.

Post-Inflammatory Hyperpigmentation (PIH)

• This occurs after skin inflammation such as acne, burns, or eczema
• The area becomes darker due to an overproduction of melanin

"Jaundice"-Yellow color skin

• Jaundice occurs when there is a buildup of bilirubin in the blood
• Bilirubin is a yellow pigment produced when red blood cells break down

Causes of Jaundice

• Hepatic Jaundice - Occurs when the liver is damaged and unable to process bilirubin
• Hepatitis - Inflammation of liver
• Cirrhosis - Scarring of liver due to alcohol abuse
• Liver cancer - Malignant tumors

Erythema Skin

• Check for skin redness, and if it can associated with rashes or other skin conditions.

Hyperpigmentation Skin

• Confined in an area birthmark

Hypopigmentation Skin

• Vitiligo (patches of hypopigmented skin), albinism

Vitiligo Skin Condition

• Vitiligo is a long-term skin condition that causes patches of the skin to lose their color
• This occurs when melanocytes,cells that produce melanin (pigment that gives skin its color), are destroyed or stop workings

Inspect skin legions

• Inspect for skin breakdown

Inspect skin for primary, secondary, or vascular lesions

• Note the size, shape, location, distribution, and configuration
• Use a wood lamp if fungus is suspected.

Skin assessment - Primary

• Those that appeared initially in response to some change in external or internal environment of the skin
• Macule path, papal, plaque, nodule tumor, papular drug eruption, psoriasis, cyst, wheal

Macule Patch

• Flat unelevated change in color
• Macules are 1mm to 1 cm (0.04to 0.4 in.) in size and circumscribed
• Freckles, measles, petechiae, flat moles
• Patches are larger than 1cm (0.4) and irregular shaped
• Port wine birthmark, vitiligo (white patches), rubella

Papule

• Circumscribed solid elevation of skin.
• Papules are less than 1cm Example
• Warts, acne, pimples,elevated moles..

Papular Drug Eruption

• Vesicle or bulla filled with pus
• Acne vulgaris, Impetigo
• Vesicle:A small, fluid filled blister, lesss than 5mm in diameter Think of a tiny bubble on the skin
• Acne vulgaris is often caused by “acne”

Plaque

• Plaques are larger than 1cm (0.4 in)
• Psoriasis, rubeola

Nodule and Tumor

• Elevated, solid mass that extends deeper into the dermis than a papule
• Nodules have a circumscribed border and are 0.5 to 2cm
• Squamous cell carcinoma. Fibroma
• Tumors are larger 2cm (0.8in) and an irregular border
• Malignant melanoma, hemangioma

Vesicle Bulla

• A circumscribed, round or oval, thin translucent mass filled with serous fluid or blood
• Vesicles are less than 0.5 cm (0.2 in)
• Herpes simplex, early chicken pox, smalls burn blister
• Bullae are larger than 0.5 am (0.2 in.)
• A large than example

Digital Mucous Cyst

• Contains a 1-cm (0.4in.) Or larger, elevated, encapsulated, fluid-filled or semisolid mass arising from the subcutaneous tissue or dermis
• Examples include sebaceous and epidermoid cysts, chalazion of the eyelid

Wheal Skin Condition

• Reddened, localized collection of edema fluid with irregular shape and size variations
• Hives, mosquito bites

Skin: Secondary

• Secondary skins those who do not appear initially but results from modification such as chronicity, trauma, or infection of the primary lesions

Skin: Secondary - Atrophy

• Occurs in epidermis, thinning of the outermost layer of the skin-epidermis
• A dermis-middle layer of the skin
• STRIAE, AGED SKIN

Skin: Secondary - Erosion

• Wearing away of the superficial epidermis causing a moist, shallow depression.
• Because erosions do not extend into the dermis. They heal without scarring
• Scratch marks, ruptured vesicles

Skin: Secondary - Lichenification

• Rough, thickened, hardened area of epidermis resulting from chronic irritation.
• Chronic dermatitis

Skin: Secondary - Scales

• Shedding flakes of greasy, keratinized skin tissue.
• Color may be white, gray, or silver. Texture may vary from fine to thick.
• Dry skin, dandruff, Psoriasis.

Skin: Secondary - Crust

• Dry blood, serum or pus left on the skin surface when vesicles of pustules burst
• Can be red-brown, orange, or yellow
• Large crust that adhere to the skin surface are called scrabs
• Eczema, impetigo, herpes, or scrabs after abrasion

Skin: Secondary - Ulcer

• Deep irregular shaped area of skin loss extending into the dermis or subcutaneous tissue
• Pressure ulcers, stasis ulcers, chancres

Skin: Secondary - Fissure

• Linear cracks with sharp edges extending into the dermis
• Cracks at corners of the mouth or hands, athlete's foot

Skin: Secondary - Scar

• Flat, irregular area of connective tissue left after a lesion or wound has healed
• New scars may be red or purple: older scars may be silvery or white
• Healed surgical wound/injury, healed acne

Skin: Secondary - Keloid

• Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing
• Extends beyond the site of the original injury
• Higher incidence in people of African descent
• Keloid from ear piercing or surgery

Skin: Secondary - Excoriation

• Scratches, some chemical burns

Skin: Palpates Lesions

• Palpating a lesion means feeling it with your fingers
• SIZE: How big is it
• SHAPE: Is it round or irregular
• TEXTURE: Is it smooth rough form, soft or rubbery
• MOBILITY: Can it be moved around easily, or is it fixed in place
• TENDERNESS: Does it hurt, when pressing on it

Specific Palpation Maneuver: Auspitz Sign

• Scraping scales of a psoriatic plaque can cause bleeding points
• Bleeding point is known as the Auspitz

Specific Palpation Maneuver: Nikolsky Sign

• Lateral pressure on a bulla in pemphigus or Stevens-Johnson syndrome, can cause the epidermis to detach from the dermis
• This is known as the Nikolsky Sign

Dimple Sign/Fitzpatrick's Sign

• Pressing on the sides of a dermatofibroma can cause a dimple
• They are common, benign, fibrous skin tumors that appear as firm, brown, or skin-colored nodules
• Often found on the legs, though they occur anywhere on the body

Skin: Palpates Texture

• (Rough or Smooth) Using palmar surface of three middle fingers

Skin: Palpates Texture Rationale

• Palpation allows healthcare professionals to feel for subtle changes in skin texture that may not be visually apparent.
• This helps differentiate between conditions, such as scaling, texture changes and temperature

Skin: Palpates Temperature

• Check for if it is cool, warm, hot, and moisture (dry, sweaty and oily) of skin , using dorsal side of hand.
• Rationale: Dorsal (back) surface of the hand to palpate for temperature; thinner skin on the back of the hand is more sensitive to temperature compared to the palm

Skin: Palpates Thickness of Skin

• Use finger pads.
• Sensitivity
• Precision
• Adaptability
• Look for normal skin, thickened skin or thinned skin

Skin: Palpates Mobility and Turgor

• Palpate skin mobility and turgor to help differentiate between various skin conditions/medical problems
• Skin mobility refers to the skin's ability to move freely over the underlying tissues
• Assessment to assess skin mobility, lift a fold of skin and observe how easily it moves

Palpates Skin Mobility Significance

• Decreased Mobility signifies edema, inflammation
• Increased Mobility signifies loose skin

Palpates for Edema

• Palpate edema pressing thumbs over feet or ankles
• Edema is presence of excess fluid in interstitial space
• Anasarca is generalized edema
• Assess presence (location, color, temperature, shape and degree to which skin remains indented or fitted, when pressed by a finger

Assessing Edema Grading

• +1 - 2mm depression, immediate rebound
• +2 - 4mm deep pit, 10-12s to rebound
• +3 -6mm deep pit, 10-12s to rebound
• +4 - MM Very deep pit; >20s Rebound

Scalp and Hair Assessment

• Inspection: inspect client's scalp and hair for color, amount, distribution, and any signs of lesions or parasites
• Palpation: palpate the scalp and hair to assess thickness, texture, oiliness, and parasites

Scalp and Hair Assessment: Inspect Color

• Check for the hair color
• Hair color is faded and appears red, texture is course and dry
• (Kwashiorkor)- severe protein deficiency

Scalp and Hair Assessment: Inspect Evenness

• Check evenness of growth over the scalp and check patches of hair loss (alopecia)

Scalp and Hair Assessment: Inspect Thinness and Thickness

• Look for thin hair (related to hypothyroidism)

Scalp and Hair Assessment: Inspect Texture and Oiliness

• Check texture and oiliness of hair: brittle hair (hypothyroidism, excessively oily, or dry hair

Scalp and Hair Assessment: Inspect Presence of Infections

• Note presence of infections/infestations by parting the hair in several areas
• Check behind ears and along hairline at neck
• Flaking, sores, lice, ringworm.

Scalp and Hair Assessment: Inspect Amount of Body Hair

• Hirsutism describes excessive hairiness in women
• Naturally absent or sparse leg hair (related to poor circulation)

Nail Assessment includes consideration of:

• Grooming and cleanliness
• Color markings
• Shape
• Texture and Consistency

Nail Assessment: Inspect for Grooming and Cleanliness

• Nails are the "window" to overall health

Nail Assessment: Inspect Color and Markings

• Color Marks indicate: Oxygen deprivation, circulatory/congenital problems

Nail Assessment: Color and Markings Signficance

• Red fingernails indicate possible brain hemorrhage, heart disease, or hihg BP

Nail Assessment: Inspect Shape

• Inspect plate shape, angle between the fingernail and the nail bed, bedding texture, bedding color, and the tissues around the nails

Normal Nail Shape

Koilonychia Nail Shape

Beau's Lines Nail Shape

Nail Assessment: Clubbing

• Condition where the angle between the nail and the nail bed is 180 degrees, or greater
• Caused by long-term lack of oxygen

Excessive thickness of nails

• Indicates presence of poor circulation or in relation to chronic fungal infection

Excessively thin nails

• Presence of grooves/furrows
• Can reflect prolonged iron-deficiency anemia

Beaus Lines presence

• Horizontal depression in the nail that can result from injury or illness

Nail Assessment: Cyanosis and Pallor

• Show signs of altered blood flow and oxygenation
• Indicates different underlying issues

Nail Assessment: Onychomycosis

• Fungal Infection
• Show Symptoms brittleness, discoloration, thickening, distortion of nail shape, crumbling of the nail, loosening / detaching of the nail

Capillary Refill Test

• Performed to assess the client's peripheral circulation
• Gently press on the client's fingernail until it blanches
• Release the pressure and observe how quickly the color returns
• Normal capillary refill is less than 2 seconds