Skin, Nail, Hair Assessment

Skin, Nail, Hair Assessment Overview

• Assessment involves subjective and objective data collection, technique and normal findings, and documentation
• Technique includes inspection and palpation

Subjective Data Collection: History and Risks

• In family history, determine if first-degree relatives had melanoma and who had the problem
• Learn if relatives have multiple dark, irregular moles
• In past history, understand frequency of skin self-exams and date of last clinical skin exam

Subjective Data Collection: Skin Lesions & Sun Exposure

• Ask if there are any pigmented skin lesions, how many, and where they are
• Find out if they have changed in itching, bleeding, nonhealing, color, size, or borders
• Discover if there was a history of severe sunburn, especially in youth
• Assess how long it takes for the skin to turn red in the sun

Subjective Data Collection: Medical History

• Ask if the patient ever had skin cancer, when, where, and how it was treated
• Learn if the patient has had an organ transplant, HIV/AIDS, chemotherapy, or radiation therapy

Subjective Data Collection: Medications and Behaviors

• Investigate what medications the patient is taking
• Discover known allergies to medications, latex, nuts, bees, or other items and if patient is allergic to sunscreen
• Consider occupation, hobbies, and exposure to sunlight or other radiation sources
• Inquire about methods used to protect against excessive sun exposure and determine the risk for skin breakdown
• Evaluate for diabetes mellitus, peripheral vascular disease, and sensory loss

Objective Data Collection: Equipment

• Examination gown is needed
• Tape measure is needed
• Adequate light source is needed
• Magnifying glass is needed

Technique and Normal Findings: Inspection

• Inspect all body areas, starting with the head and progressing to the feet
• Part hair to visualize the scalp; make sure to assess the soles and separate the toes
• Note general skin color
• Normal findings include consistent body pigmentation
• Patients with dark skin may have hypopigmented palms and soles

Technique and Normal Findings: Lesions Inspections

• Inspect any lesions
• If lesions are observed, identify morphology, configuration, distribution pattern, size, and exact location
• Common benign lesions include freckles, birthmarks, skin tags, moles, and cherry angiomas

Lesion Configurations: Descriptors

• Annular lesions are ring-like and circular
• Arciform lesions are half-ring in shape
• Linear lesions are line-shaped
• Polymorphous lesions have several different shapes
• Serpiginous lesions are curving and snake-like
• Nummular/Discoid lesions are coin-shaped
• Umbilicated lesions have a central depression

Lesion Configurations: Descriptors 2

• 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: Types

• Asymmetric distribution occurs 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, whereas symmetric distribution occurs equally on both sides of the body

Skin Lesions: Primary vs Secondary

• Primary skin lesions are present at the onset of a disease
• 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 skin lesions evolve from primary lesions or develop as a consequence of the patient's activities

Skin Lesions: Types

• Primary lesions include macule, papule, patch, plaque, nodule, vesicle, and bulla
• Secondary lesions include ulcer, crust, atrophy, scar, erosion, and fissure

Skin Assessment: Wounds and Infections

• Identify any infections and use infection-control principles if infection is suspected
• Note any inflammatory lesions and observe for growths, tumors, or vascular lesions
• Inspect wounds or incisions, noting shape, length, width, and depth; use a cotton applicator to measure depth if needed
• Describe wounds related to trauma and assess blood supply, noting bleeding or bruising

Assessing Skin Breakdown Risk

• Identify the risk for skin breakdown, especially in hospitalized or inactive patients
• Classify any wound as partial or full thickness
• Identify the presence and stage of any pressure ulcer
• Observe and document the size in depth and diameter along with margins
• Assess condition of surrounding tissues, drainage, odor, or necrotic tissue
• Describe the color and texture of the tissue
• Identify the amount, color, consistency, and odor of exudate and use appropriate landmarks

Nail Assessment: Inspection

• Inspect each fingernail and toenail for color, thickness, and consistency
• Normal nails are smooth, translucent, and consistent in color and thickness
• However longitudinal ridging is common in aging patients
• Longitudinal pigmentation in dark-skinned patients is a normal variant
• Evaluate the nail angle and that the nail angle of at least 160 degrees

Fingernail Assessment: Abnormal Findings

• Spoon Nails - transverse and longitudinal concavity of the nail, giving the appearance of a spoon that may be normal in infants or occur because of trauma
• Pitted Nails - Psoriatic lesions that arise from nail matrix causing pitting occurs on the nail plate as it grows
• Longitudinal ridging - Normal variation, especially in elderly
• Yellow Nails - slow growing nail without cuticle, and onycholysis resulting in the thickening of nail and yellowish appearance

Fingernail Assessment: Abnormal Conditions

• Beau's Lines - results from slowed or halted nail growth in response to illness, physical trauma, or poisoning.
• Mee's Lines - single transverse white band, also from poisoning
• Clubbing - results from chronic hypoxia to distal fingers with emphysema or congestive heartfailure

Hair Assessment: Inspection

• Inspect the hair, noting color, consistency, distribution, areas of hair loss, and condition of the hair shaft
• Hair should be equally and symmetrically distributed across the scalp
• Note areas of decreased or absent hair, visualizing the scalp skin by parting the hair
• Identify presence of lesions or color changes; Scalp skin should be of color consistent with the rest of the body

Abnormal Hair Findings

• Alopecia Areata is an autoimmune disorder that results in noninflammatory loss of hair in a circumscribed distribution

Palpation: Skin Temperature

• Use the dorsal surface of the hands and assess skin temperature
• Consistent skin temperature of warm or cools is considered normal
• Skin temperature should be appropriate to the environment

Palpation: Skin Moisture and Texture

• Assess skin moisture and texture using the palmar surface of the fingers and hands with, even consistency throughout

Palpation: Skin Turgor

• Assess skin turgor by grasping a fold of the patient's skin between fingers
• Pull up gently, release, and observe the prompt return of the skin to its normal position

Palpation: Skin and Hair Exam

• Assess for vascularity by applying direct pressure to the skin surface using the pads of your fingers; promptly should return to normal
• Palpate lesions for tenderness, mobility, and consistency
• Palpate each fingernail and toenail
• Check that nails are smooth, nontender, and firmly adherent to the nail bed with lateral and proximal folds that are nontender and nonswollen
• Grasp 10 to 12 hairs and gently pull to check if a few hairs are extracted

Normal Subjective and Objective Documentation

• The patient denies pruritus, skin lesions, and excessive dryness of the skin, or changes to existing moles
• Skin is evenly colored, smooth, soft, consistently warm, and has turgor
• Nails are smooth and transluscent, and exhibit lateral and proximal folds without swelling or erythema
• Hair exhibits smooth texture, symmetric distribution on the scalp, is consistent in coloration and hydration, and is without evidence of excessive breakage or loss
• Scalp exhibits consistent pigmentation and the absence of lesions