Skin, Nail, Hair Assessment

Skin, Nail, Hair Assessment Overview

• This assessment includes subjective and objective data collection, techniques for examination (inspection, palpation), and documentation of findings.

Subjective Data Collection: History and Risks

• Determine if any first-degree family members have a history of melanoma.
• Determine if any first-degree relatives have multiple dark, irregular moles.
• Determine if the patient performs monthly self-skin examinations and when their last clinical examination was.
• Ask about any past severe sunburns, especially during youth, and how long the patient can be int he sun before their skin turns red.
• Determine how the patient reacts if they are allergic to something.
• Determine what medications the patient is taking.
• Determine if the patient has allergies to medications, latex, nuts, bees, or other items.

Subjective Data Collection: Additional History and Behaviors

• Investigate any history of pigmented skin lesions: quantity, location, changes (itching, bleeding, non-healing, color change, size, borders).
• Inquire about prior skin cancer, including when and where, and treatment.
• Look out for history of organ transplant, HIV/AIDS, chemotherapy, or radiation therapy.
• Assess lifestyle, occupational history, and personal behaviors; including occupation, hobbies, exposure to excessive sunlight or radiation, and sun protection habits.
• Evaluate risk for skin breakdown as well as the existence of diabetes mellitus, peripheral vascular disease, or sensory loss.

Objective Data Collection: Equipment Needed

• Required equipment is an examination gown, tape measure, adequate light source, and magnifying glass.

Technique and Normal Findings: Inspection

• Inspect all body areas.
• Start with patient's head
• Progress to the feet.
• Part the hair to visualize the scalp.
• Assess the soles and skin between the toes.
• Note the patient's general skin color
• Expected normal findings include consistent body pigmentation and, for patients with darker skin, possibly hypopigmented palms and soles.
• When lesions are found note their morphology, configuration, distribution pattern, size, and location.
• Common benign lesions include freckles, birthmarks, skin tags, moles, and cherry angiomas.

Lesion Configurations

• Annular lesions are ring-like and circular.
• Arciform lesions are half-ring shaped.
• Linear lesions are line-shaped.
• Polymorphous lesions have several different shapes.
• Serpiginous lesions are curving, snake-like.
• 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 similar to tongue papillae.

Lesion Distribution Patterns

• Asymmetric distribution exists solely on one side of the body.
• Diffuse distribution is widely across the affected area without any pattern.
• Localized distribution is in a distinct area.
• Symmetric distribution is equal 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 disease progression, manipulation, or treatment.
• Secondary lesions evolve from primary lesions or develop as a consequence of the patient's activities.

Primary Skin Lesions Types

• Macules are flat.
• Papules are raised.
• Bullas are fluid filled and are >1 cm.
• Vesicles are filled with fluid and are <1cm in diamater.

Secondary Skin Lesions Type

• Ulcers have loss of skin.
• There is thinning of skin with atrophy.

Technique and Normal Findings: Inspection - Continued

• Assess patient for any infections.
• Check for consistent color and thickness.
• Longitudinal pigmentation is a normal variant in dark-skinned patients. Inspect each fingernail and toenail. Assess color, thickness, and consistency.
• Examine if the shape and measure the length, width, and depth of any wounds or incisions.
• If the wound is deep or tunneled, use a cotton applicator to measure depth.
• Identify any infections and use infection-control principles if suspected.

Technique and Normal Findings: Hair and Nails

• Inspect the hair: note color, condition, consistency, distribution, areas of hair loss.
• The hair should be equally and symmetrically distributed across the scalp.
• Note any lesions or color changes, and whether the scalp skin color is consistent with the body.
• Have the patient place their fingernails together to check the nail angle, and check for wounds, bleeding or bruising.
• A normal nail should have, smooth texture, translucence, good color and thickness.
• Use infection-control principles if infection suspected.
• Make sure to separate and asses soles of feet and areas between toes, and measure depth with a ruler of the wound.
• The presenc of longitudinal ridging is normal in aging patients.

Technique and Normal Findings: Palpation

• Use the dorsal surface of the hands to assess skin temperature (consistently warm or cool and appropriate to the environment).
• Use the palmar surface of the fingers and hands to assess skin moisture and texture.
• The skin moisture should be consistent throughout, with evenly smooth skin texture.
• Grasp a fold of the patient's skin and check that it promptly recoils to it's normal position
• The lateral and proximal folds should be nontender and nonswollen.
• There should only be a few hairs are pulled out when palpating the patient's hair.
• On releasing the finger, color should return to normal promptly. and palpate the skin for tenderness, mobility and consistency.
• The nails are smooth, nontender and firmly adherent to the nail bed.

Documentation of Normal Findings

• The patient denies pruritus (itching), skin lesions, and excessive dryness.
• The patient denies changes to existing moles. Skin is evenly colored, smooth, soft, consistently warm, with intact turgor. No suspicious lesions are noted
• Nails are smooth and translucent, with lateral and proximal folds without swelling or erythema as well as smooth texture, symmetrically distributed on the scalp, consistent coloration and hydration, without evidence of excessive breakage or loss. Scalp has consistent pigmentation and no lesions are noted.