Skin, Nail, Hair Assessment

Skin, Nail, Hair Assessment Overview

• Subjective data collection and objective data collection are the two main components of skin, nail, and hair assessment
• Technique and normal findings, split into inspection and palpation, are part of objective data collection
• Documentation of normal subjective and objective findings is important

Subjective Data Collection

• Assess history and risks through questioning
• Family history questions include; if first-degree relatives have a history of melanoma and who had the problem, and if any relatives have multiple dark, irregular moles
• Past history questions include; frequency of skin self-exams, the date of the last clinical skin exam, if any pigmented skin lesions exist, how many and where they are
• Other past history questions include; if there have been any changes to skin, the severity of sunburns during youth, and how long it takes for the skin to turn red in the sun
• More questions include; previous instances of skin cancer, organ transplants, HIV/AIDS, and chemotherapy or radiation therapy
• It is important to ask what medications are currently being taken
• Ask about allergies to medications, latex, nuts, bees, and sunscreen
• It is important to ask about lifestyle, occupational history, and personal behaviors; including occupation, hobbies, exposure to sunlight or other radiation sources, and sun exposure protection measures
• Assess the risk for skin breakdown
• Ask about diabetes mellitus, peripheral vascular disease, and any known sensory loss

Objective Data Collection

• Necessary equipment includes an examination gown, tape measure, adequate light source and a magnifying glass

Technique and Normal Findings: Inspection

• Inspect all body areas, starting with the head and progressing to the feet
• Part the hair to visualize the scalp
• Ensure to assess the soles and separate the toes
• General skin color must be noted
• Normal findings are consistent body pigmentation and potentially hypopigmented palms and soles in patients with dark skin
• Inspect for lesions and identify morphology, configuration, distribution pattern, size, and exact 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 consist of several different shapes
• Serpiginous lesions are curving and snake-like
• Nummular/discoid lesions are coin-shaped
• Umbilicated lesions have a central depression
• Punctuate lesions are small and marked with points or dots
• Filiform lesions are papilla-like or finger-like projections, similar to tongue papillae

Lesion Distribution Patterns

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

Primary and Secondary Lesions

• Primary skin lesions are present at the onset of a disease vs secondary lesions
• 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

• Macules are flat freckles
• Papules are Mura
• Patches can be seen
• Plaques are Leve
• Nodules are Ben
• Vesicles are Kabarcık
• Bullas are Bl

Secondary Skin Lesions

• Ulcers are Yara (Denn)
• There are crusts
• Atrophy shows skin loss
• Scars are Yara izi
• Erosion is visible
• Fissures are çizme

Skin Tumors and Growths

• Lipomas exhibit single or multiple tumors of different sizes, comprising fat cells commonly found on the back of the neck, torso, arms, and legs and some varieties are painful
• Lentigines are acquired, circumscribed, pigmented macules generally found on sun-exposed skin
• Squamous Cell Carcinomas: the second most frequent skin cancer is related to actinic keratosis and sun exposure, and lesions are typically papular, modular, or plaques
• Kaposi Sarcoma: opportunistic skin infection is a consequence of impaired immune status and lesions occur on the nose, penis, and extremities
• Basal Cell Carcinoma: a modular or papular skin cancer appears shiny with a rolled pearly border, spider veins on its surface, grows slowly and rarely metastasizes

Technique and Normal Findings: Inspection Continued

• Identify any infections and use infection-control principles if an infection is suspected
• Note any inflammatory lesions
• Observe for growths, tumors, or vascular or other lesions
• If there is a wound or incision, take note of the shape and measure the length, width, and depth with a ruler
• If a wound is deep or tunneled, insert a cotton applicator to measure depth
• Describe wounds related to trauma, Assess the status of the blood supply to the skin, and note any bleeding or ecchymosis
• Identify the risk for skin breakdown, especially in hospitalized or inactive patients
• Classify the wound as partial or full-thickness and if a pressure ulcer is present, identify the stage
• Observe and document the size in depth and diameter margins, condition of surrounding tissues, and any drainage, odor, or necrotic tissue
• Describe the color and texture of the tissue
• Identify the amount, color, consistency, and odor of exudate (drainage) and use appropriate landmarks
• For non-pressure ulcers, note the characteristics of the wound
• Inspect each fingernail and toenail
• Assess color, thickness, and consistency of nails
• 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
• To assess the nail angle, have the patient place the fingernails of both index fingers together
• A diamond-shaped opening that is visible between the two fingernails indicates a nail angle of at least 160 degrees
• 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, and parting the hair enables visualization of the scalp skin
• On the scalp skin, note any lesions or color changes
• Scalp skin should be of a color consistent with the rest of the body

Abnormal Nail Findings

• Koilonychia (Spoon Nails): Transverse and longitudinal concavity of the nail and may be normal in infants but other causes include; trauma, iron-deficiency anemia, and hemochromatosis
• Pitted Nails: Psoriatic lesions arise from the nail matrix and cause pitting on the nail plate
• Longitudinal Ridging: Considered as normal variation, especially in elderly
• Yellow Nails: can be a sign of jaundice and characterized by slowly growing nail without cuticle
• Clubbing: caused from chronic hypoxia to distal fingers
• Beau's Lines: Results from slowed or halted nail growth in response to illness, physical trauma, or poisoning
• Alopecia Areata: An autoimmune disorder results in noninflammatory loss of hair in a circumscribed distribution

Technique and Normal Findings: Palpation

• Use the dorsal surface of the hands to assess skin temperature
• Skin temperature should be consistently warm or cool and appropriate to the environment
• Use the palmar surface of the fingers and hands to assess skin moisture and texture
• Moisture should be consistent throughout, with evenly smooth skin texture
• To assess skin turgor, gently grasp a fold of the patient’s skin between the fingers and pull up before releasing the fold
• Skin should promptly recoil to its normal position
• To assess for vascularity, apply direct pressure to the skin surface with the pads of the fingers, and on releasing the finger/color should promptly returns to normal
• Palpate lesions for tenderness, mobility, and consistency
• Palpate each fingernail and toenail
• Nails should be smooth and nontender, and firmly adherent to the nail bed
• Lateral and proximal folds are nontender and nonswollen
• Palpate the hair
• Grasp 10 to 12 hairs and gently pull and only a few hairs should be in your hand

Documentation of Normal Subjective and Objective Findings

• The patient denies pruritus, skin lesions, and excessive dryness of skin, alongside denying changes to existing moles
• Skin evenly colored, smooth, soft, consistently warm, with intact turgor and without suspicious lesions
• Nails smooth and translucent plus lateral and proximal folds without swelling or erythema
• Hair smooth texture, symmetrically distributed on the scalp, consistent coloration and hydration, and without evidence of excessive breakage or loss
• Scalp with consistent pigmentation and without lesions noted