Skin, Nail, and Hair Assessment

Skin, Nail, and Hair Assessment Overview

• The assessment includes subjective and objective data collection
• Techniques and normal/abnormal findings are evaluated
• Documentation of the findings are recorded

Subjective Data Collection

• Subjective data involves gathering the patient's history and risk factors
• It's determined if any first-degree family members have a history of melanoma, if yes, which family member
• Assessment if any first-degree relatives have multiple dark, irregular moles is done
• Assess how often the patient does skin self-examinations is noted
• The date of their last clinical skin examination is determined
• If the patient has any pigmented skin lesions and where they are located recorded
• Inquiry if the lesions have changed in itching, bleeding, nonhealing, color, size, or borders
• The patient is asked if they ever had severe sunburn, particularly during their youth
• Assess how long the patient can be in the sun before their skin begins to turn red
• Determine of the patient ever had skin cancer, when, where, and how it was treated is noted
• Evaluate if the patient has had chemotherapy or radiation therapy
• Determine if the patient has any allergies to medications, latex, nuts, bees, or other items
• Question what medications the patient is currently taking
• Document how the patient reacts to their allergy

Objective Data Collection

• Physical examination, requires specific equipment
• Needed equipment includes an examination gown, tape measure, adequate light source, and a magnifying glass

Techniques and Normal Findings-Inspection

• All body areas should be inspected, start with the head
• Part hair to visualize the scalp and progress to the feet for examination
• Make sure to assess the soles and separate the toes
• General skin color should be noted in the assessment
• Note lesions if present, observe if identified
• Identify the morphology as well as configuration, distribution pattern, size, and exact location
• Common benign lesions include freckles, birthmarks, skin tags, moles, and cherry angiomas
• Normal findings include consistent body pigmentation
• Patients with dark skin may have hypopigmented palms and soles

Lesion Configurations

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

Lesion Distribution Patterns

• Asymmetric distributions appear solely on one side of the body
• Diffuse distributions are widely across the affected area
• Localized distributions are in a distinct area
• Symmetric distributions are on both sides of the body

Primary and Secondary Skin Lesions

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

Primary Skin Lesions

• Macule
• Papule
• Patch
• Plaque
• Nodule
• Vesicle
• Bulla

Secondary Skin Lesions

• Ulcer
• Crust
• Atrophy
• Scar
• Erosion
• Fissure

Skin Tumors and Growths

• Lipoma
• Lentigo
• Squamous Cell Carcinoma
• Kaposi Sarcoma
• Basal Cell Carcinoma

Technique and Normal Findings-Inspection

• Identify any infections, use infection-control principles if infection is suspected
• Note any inflammatory lesions
• Observe for growths, tumors, or vascular/other lesions
• Inspect any wounds or incisions
• Note the shape and measure the length, width, and depth
• Use a ruler, to insert a cotton applicator to measure depth if the wound is deep or tunneled
• Detail wounds related to trauma
• Assess the status of the blood supply to the skin
• Note any bleeding or ecchymosis (bruising)
• Identify risk for skin breakdown, especially in hospitalized or inactive patients
• Determine if the wound is partial- or full-thickness; if a pressure ulcer is present identify the stage
• Observe and document the size in depth and diameter, margins, and condition of surrounding tissues
• Document any drainage, odor, or necrotic tissue; describe the color and texture of the tissue
• Use appropriate landmarks to identify the amount, color, consistency, and odor of exudate (drainage)
• Asses non-pressure ulcers and note the characteristics of the wound

Nail Inspection

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

Hair Inspection

• Inspect the hair, noting color, consistency, distribution, areas of hair loss, and condition of the hair shaft
• Hair distribution should be equal and symmetrical across the scalp
• Parting the hair enables visualization of the scalp skin and if there are any lesions or color changes is noted
• Scalp skin should be the same color as the rest of the body

Normal Findings-Palpation

• Using the dorsal surface of the hands assess skin temperature
• Skin temperature is consistently warm or cool and appropriate to the environment
• Skin moisture and texture is assessed using the palmar surface of the fingers and hands
• Moisture is consistent throughout, with evenly smooth skin texture

Palpation Technique

• Assess skin turgor by gently grasping a fold of the patient's skin between your fingers and pull up
• Skin should promptly recoil to its normal position
• Assess for vascularity by applying direct pressure to the skin surface with the pads of your fingers
• Color should return to normal on the release of your finger
• Palpate lesions for tenderness, mobility, and consistency
• Palpate each fingernail and toenail
• Nails should be smooth, nontender, and firmly adherent to the nail bed, and lateral and proximal folds are nontender and nonswollen
• Palpate the hair, grasp 10 to 12 hairs and gently pull, there should only be a few hairs in your hand

Documentation

• Record normal findings if the patient denies pruritus, skin lesions, and excessive dryness of the skin
• Denies changes to existing moles
• Note skin color, smooth, soft, consistently warm, with intact turgor
• Document no suspicious lesions, and record nail smoothness and translucence as well as lateral and proximal folds without swelling or erythema
• Make note of hair texture, distribution as well as consistent coloration and hydration without any evidence of excessive breakage or loss
• Scalp consistency in pigmentation and note of any lesions