Course: Health Assessment�Unit Title: Skin, hair and nails Assessment�Population:

Sarah Rowe, MSN-RN

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Developed: June 2018 Copyright Nurses International 2018

Module Goals

Learner Outcome:

• At the completion of these modules the learner will demonstrate knowledge and skills to perform a complete health assessment of an individual.

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Module Objectives

• Explain the processes, procedures and techniques in the assessment of the skin, hair and nails.
• Differentiate between normal and abnormal assessment findings of the skin, hair and nails
• Outline the nurse’s actions in the assessment of the skin, hair and nails

Assessment Process/Procedure: Subjective Data

Subjective Data questions to ask the patient

• Ask about history of skin diseases
• Psoriasis, rashes, eczema, allergic reactions
• Any change in skin color?
• Any change in mole? (color or size)
• Skin too dry or too moist?
• Current pruritis(itching) or irritation?

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Assessment Process/Procedure: Subjective Data

• Does skin bruise easily?
• Rashes or lesions present?
• Current medications (prescribed and over-the-counter)?
• Recent hair loss or change in hair texture?
• Change in nails (strength, texture)?
• Exposure to environmental or occupational hazards?
• Increased sun exposure, exposure to chemicals, irritants, etc.

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Assessment Process/Procedure: Objective Data �

• Conduct assessment in a room with good lighting
• Supplies needed: centimeter ruler, penlight, gloves, Wood’s light
• Start assessment with inspection/palpation of hands and fingernails for patient comfort
• Inspect skin folds, underneath breasts, and groin thoroughly
• Always remove socks and shoes to assess feet, toes, and in-between toes

*the skin is not assessed separately, assessed with the other body systems in a head-to-toe fashion.

Assessment Process/Procedure: Objective Data

• Skin Assessment
• Observe general skin tone
• Should be even, wide range of normal color
• Observe freckles and moles
• Small, flat moles are considered normal
• Mole=nevus
• Flat= macular
• Raised= papular

Assessment Process/Procedure: Objective Data

Use ABCDE to identify potentially malignant moles

• Asymmetry
• Border irregularity
• Color variation
• Diameter>6mm
• Elevation/evolution

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Assessment Findings

Moles (nevi)

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A. Macular nevi

B. Papular nevi

C. Malignant Melanoma(abnormal)

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Assessment Process/Procedure: Objective Data

• Observe birthmarks
• Mongolian spots can be mislead the healthcare provider, appear to be caused by abuse
• Inspect for widespread color changes
• Pallor, erythema, cyanosis, jaundice
• In dark skinned patients it is best to assess for widespread color changes:
• Under tongue, buccal mucosa, palpebral conjunctiva, and sclera

Abnormal Assessment Findings�

General Coloring

A. Cyanosis

B. Erythema

C. Jaundice

D. Vitiligo

E. Mongolian spot

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Assessment Process/Procedure: Objective Data

• Temperature
• Use the dorsal surface to feel temperature of skin
• Skin should be warm, extremities may be cooler
• Moisture
• Assess for excess moisture (diaphoresis) or dryness
• Texture
• Smooth, firm with even surfaces

Assessment Process/Procedure: Objective Data

• Thickness
• Assess for areas of thickened(callused) or thin skin (may appear shiny)
• Edema
• Press thumb against ankle malleolus or tibia for 3-4 seconds
• Skin should return quickly
• If indentation stays it is considered “pitting”
• Pitting is graded on a 1-4+ scale
• Look for unilateral or bilateral edema (anasarca)

Assessment Process/Procedure: Objective Data

• Mobility/turgor
• Pinch skinfold on anterior chest, under clavicle
• Mobility= ease of skin rising
• Turgor= ability of skin to return to baseline
• Indicator of fluid volume status
• Vascularity/bleeding
• Cherry angiomas are 1-5mm red raised dots that appear on trunk
• Pay attention to bruising
• Multiple bruises in different stages of healing can indicate abuse

Abnormal Assessment Findings

Bruises/Vascular Markings

A. Purpura

B. Ecchymosis, bruise

C. Stages of bruising

D. Cherry angioma

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Assessment Process/Procedure: Objective Data

• Inspect lesions carefully
• Don gloves if necessary
• Note:
• Color
• Elevation(flat? raised?)
• Pattern/shape
• Size (measure, in centimeters)
• Location/distribution on body
• Exudate, note color and odor

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Assessment Process/Procedure: Objective Data

Lesions, cont’d

• There are many skin disorders and other systemic disorders that have characteristic lesions.
• It is important to be as descriptive as possible and use accurate terminology
• A primary lesion is the initial lesion caused by the disease/disorder
• A secondary lesion is further damage to or infection of the primary lesion, usually from itching

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Lesion configuration and distribution terms �

Abnormal Assessment Findings

Skin Lesions

4 Stages of Pressure Ulcers

Chart of different primary lesions

Assessment Process/Procedure: Objective Data

Hair Assessment

• Check scalp for lesions, lice, etc.
• Color
• Texture (fine to thick)
• Distribution of hair
• Note thinning or excess hair over different areas
• Thinning can be associated with hypothyroidsim, other disorders.

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Abnormal Assessment Findings

A.Female with hirsutism

B.Male pattern baldness

C.Head lice

Assessment Process/Procedure: Objective Data

Nails Assessment

• Inspect/ palpate the nails
• Look at the shape and contour of nail
• Nail edges should be clean, smooth and round
• Profile sign
• look at the nail from the profile view
• note the angle of nail compared to nail base
• normal is about 160 degrees

Assessment Process/Procedure: Objective Data

Nails Assessment

• Texture-should be smooth
• Color- should have a pinkish nail bed
• Check capillary refill
• Depress the nail edge to blanch and release
• Note how long it takes for color to return to nail bed
• Normal capillary refill= 1-2 seconds
• Useful for assessment of oxygenation/perfusion

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Abnormal Assessment Findings

 Spoon nail

Clubbing

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Beau’s line

Objective Data: Age specific considerations

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Pregnant women

• Increased hormones result in increased pigment in areolas and nipples
• "Vascular spiders" / palmar erythema
• Connective tissue is more fragile, leads to striae gravidarum (stretch marks)

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Infants and Children

• Lanugo= fine hair on body of newborn
• Vernix caseosa= thick, cheesy substance covering skin at birth

Adolescents

• At puberty increased secretions from sebaceous glands
• Skin oily
• Acne common

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Objective Data: Age specific considerations��The Aging Adult�

• Slow atrophy of skin structures
• Decreased elasticity, outer layer thins and flattens
• Increased wrinkles and folds

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• Decreased activity of sweat and sebaceous glands
• Minor trauma can cause dark discolored areas= senile purpura
• Delayed wound healing

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Objective Data: Age specific considerations

The aging adult

• Nails
• Grow more slowly
• Ridges are common
• Hair
• Melanocytes decrease, hair becomes grey
• Hair distribution changes, decreased hair in axillae and pubic areas

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What would the nurse do?

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• L.T. is a 65-year-old retired woman in good health with no chronic illnesses. She takes a multivitamin daily but has no prescription medications. She came to the clinic today complaining of itching, tingling, and severe pain on her right flank. Upon assessment you observe a linear, vesicular reddened rash on her right side.
• As the nurse caring for L.T. what do you initially think the patient is presenting with?
• What additional subjective information should you gather about the patient?
• What precautions should the patient take?

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Glossary

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• Alopecia- hair loss
• Cyanosis- bluish tint, mottled color
• Erythema- redness of the skin.
• Hirsutism- excess hair.
• Jaundice- yellowing of the skin. Caused by elevated bilirubin levels.
• Malignant Melanoma- cancerous lesion.
• Mongolian spot- common hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns

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• Nail clubbing- In response to lack of oxygen, nails becomes convex as it grows
• Pallor- Ashen color in dark skin or white color in light skin occurs with anemia, shock, and arterial insufficiency
• Purpura- red-purple bruising>3mm, non-blanchable.
• Spoon Nail- convex shape of nail, looks “scooped out” associated with iron deficiency

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Additional learning resources

• American Academy of Dermatologists https://www.aad.org/

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• Wound Ostomy and Continence Nurses Society https://www.wocn.org/

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• Center for Disease Control https://www.cdc.gov/cancer/skin/index.htm

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Graphic and/or Photo Citations

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Jarvis, C. (2015).Physical examination and health assessment (7th ed.), Elsevier Health Sciences.

McCance,K. Huether, S., Brashers, V.,& Rote, N. (2014). Pathophysiology: the biologic basis for disease in adults and children (7^th ed). St.Louis, MO: Elsevier.

Moiz, E. (2018) Spoon nails: still seen in today’s world. Clinical Case Reports 6(3), 547-48. Retrieved from: https://onlinelibrary.wiley.com/doi/epdf/10.1002/ccr3.1404

Sandstrom, S., Lewis, S., Buchner, L., Heitkemper, M., Harding, M., Kwong, J., & Roberts, D.(2017). Study guide: Medical surgical nursing assessment and management of clinical problems(10^th ed). St.Louis, MO: Elsevier.

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