SKIN

NAILS PHYSICAL
HAIR
ASSESSMENT
HEAD JOCELYN C TEBRERO, MAN, RN, RM
OUR LADY OF FATIMA UNIVERSITY

NECK COLLEGE OF NURSING

 SKIN

Epidermis
■ Outer layer
■ Made of squamous epithelial tissue

Dermis
■ Thick, deeper layer
■ Consists of connective tissue and an extracellular
material (matrix), which contributes to the skin’s
strength and pliability
■ Location of blood vessels, lymphatic vessels, nerves,
hair follicles, and sweat and sebaceous glands

Subcutaneous tissue
■ Beneath dermis and epidermis
■ Consists mostly of adipose and other connective
tissues
FUNCTIONS OF SKIN
PROTECTION SENSATION

HEAT ABSORPTION
REGULATION

SECRETION EXCRETION
 ASSESSMENT FINDINGS
INSPECTION NORMAL ABNORMAL
Evenly colored Jaundice
skin tones
without Pallor
unusual or
prominent Acanthosis nigricans
discolorations
GENERAL
Cyanosis
SKIN COLOR
Older client
looks pale due
to decrease
melanin
production
and vascularity
 ASSESSMENT FINDINGS
INSPECTION NORMAL ABNORMAL
Sun-tanned areas Albinism
Freckles Erythema
COLOR VARIATIONS
Vitiligo

Skin is intact and Pressure ulcers

there are no
SKIN INTEGRITY
reddened areas

Smooth, without Primary lesions

lesions Secondary lesions
Stretch marks
Healed scars
LESIONS Moles
Freckels
Birthmarks
 PRIMARY LESIONS
PAPULE
MACULE Elavated, solid
Skin color lesion of less
change without than 1cm
elevation varying in color

PATCH PLAQUE
Skin color Raised flat lesion
change greater formed from
than 1cm merging papules
or nodules
 PRIMARY LESIONS

NODULE VESICLE
Elevated, a small fluid-
palpable, solid filled bladder,
mass, 0.5-2cm sac

BULLA
TUMOR is a fluid-filled sac or
Extend deeper lesion that appears
into dermis, when fluid is
1-2 cm trapped under a
thin layer of your
skin
 PRIMARY LESIONS
CYST
WHEAL
Encapsulated
an area of the
fluid filled or semi
skin which is
solid mass
temporarily
raised, typically
Located in the
reddened, and
subcutaneous
usually
tissue or dermis
accompanied
by itching.

PUSTULE
Pus filled vesicles
 SECONDARY LESIONS

EROSION ULCER
Loss of superficial epidermis Skin loss extending dermis

Does not extend to the dermis Necrotic tissue loss

Depressed, moist area Bleeding and scarring possible

 SECONDARY LESIONS

SCAR FISSURE
Skin mark left after wound heal Linear crack in the skin

Represent replacement by connective May extend to the dermis

tissue of the injured tissue
 VASCULAR LESIONS
Ecchymosis Cherry Angioma Spider Angioma

Capillary hemangioma

Telangiectasis

Petechia

Port -wine stain

 SKIN ABNORMALITIES ECZEMA/ATOMIC
DERMATITIS
ACNE VULGARIS ACTINIC KERATOSIS
Causes redness, pruritus,
Caused by over-activity Causes reddish,
itchy, can cause skin
of sebaceous gland and irregular, slightly raised
irritation and it has red to
an onset of puberty lesions that have a
red-brown, slightly scaly
rough, gritty surface
lesions
SKIN ABNORMALITIES
Localized skin
irritation,
inflammation, and
pruritus from
contact with an
irritating substance

A contagious
disease caused by A common dermatitis that has
the herpes simplex genetic causes and may
begin at any age, Silvery
virus. Recurrent scales on bright red papules,
clusters of small Scales generally thick, Area
vesicles on beneath bleeds if scale is
erythematous base removed
 ASSESSMENT FINDINGS

PALPATION NORMAL ABNORMAL

Smooth and Rough, flaky,

TEXTURE
even dry, itchy
Diaphoresis
MOISTURE Moist and dry Decrease
moisture
Cold skin
TEMPERATURE Warm Very warm
skin
 ASSESSMENT FINDINGS
PALPATION NORMAL ABNORMAL

Skin pinches Decrease

easily and mobility is seen
MOBILITY
immediately with edema
AND
returns to its
TURGOR
original Client
position dehydrated
Skin rebounds
and does not
remain
EDEMA With indention
indented
when pressure
is released
 PHYSICAL ASSESSMENT OF THE SKIN
 Greet and identify the client
 Explain the procedure
 Wash hands
 Provide for client privacy
 Position client appropriately and
comfortably
 Inquire if the client has any history of skin
allergies and skin problems
 Inspect for the skin color and uniformity
of skin color
 Assess edema if present. Note location,
color, temperature, shape and degree to
which the skin remains indented or pitted
when pressed by a finger
 Inspect, palpate and describe skin
lesions
 Observe and palpate skin moisture
 Palpate skin temperature
 Note skin turgor
 Position the client comfortably
 Inform the client findings if
necessary
 Wash hands
 Document findings and report
significant deviation to the
physician
 QUESTIONS TO BE ASKED FROM THE CLIENT
 History of client
 Have you noticed any change in your ability to feel pain, pressure, light touch or
temperature variations?
 Are you experiencing any pain, itching, tingling, or numbness
 Are taking any medications(prescribed/over the counter) do you use any ointments,
creams, herbal and nutritional supplements or vitamins? How long have you been taking
each of these?
 Do you have any trouble controlling body odor? Do you perspire a lot?
 Have you had any recent hospitalizations or surgeries
 Have you ever had any allergic reactions to food medications, plants or other
environmental substances?
 Has anyone in your family had a recent illness, rash, or other skin problem or allegy?
 Has anyone in your family had skin cancer?
 Do you have any history of keloids?
HAIR - is formed from keratin produced by matrix
cells in the dermal layer of the skin. Each hair lies in
a hair follicle.
FUNCTION OF HAIR

PROTECTION

REGULATION OF BODY TEMPERATURE

FACILITATION OF EVAPORATION
OF PERSPIRATION

SENSE ORGAN
 ASSESSMENT FINDINGS
INSPECTION NORMAL ABNORMAL
Natural hair
COLOR Patchy gray hair
color
Excessive scaliness
MOISTURE Shiny
Poor hygiene
Presence of
dandruff and
SCALP Clean
parasites
Alopecia
Thick and Brittle hair
TEXTURE fine Split ends
Dry
 NAIL - are formed when epidermal cells are
converted into hard plates of keratin.
The cuticle, a layer of keratin at the nail fold,
attaches the nail plate to the soft tissue of the nail
fold.

The nail body is translucent, and the pinkish

hue reflects a rich blood supply beneath the nail
surface

Lunula is nail plate which is slightly hypopigmented

than nail. The lunula contains stem cells and nail plate
matrix which helps the growth of the nail. If it gets
damaged your nail cant grow well.
 ASSESSMENT FINDINGS

INSPECTION NORMAL ABNORMAL

Colorless and a
NAILS Concave
convex curve

Clubbed fingernails
Angle between
(>180°) due to
nail and nail bed
chronic tissue
usually 160°
hypoxia
Highly vascular
and pink in light Bluish or purplish
skinned; dark tinges;
skinned may be Pale
brown or black
 ASSESSMENT FINDINGS
Perform blanch test/ Capillary
refill test -is a quick test done on
the nail beds. It is used to monitor
dehydration and the amount of
blood flow to tissue.
Normal 1 – 2secs

ABNORMAL FINDINGS:
A CRT longer than 2 seconds
suggests poor perfusion due to
peripheral vasoconstriction.
SCAMROTH SIGN/SCHAMROTH WINDOW
 COMMON NAIL DISORDERS
Koilonychia Spoon-shaped nails that
may be seen with trauma to cuticles or
nail folds or in iron deficiency anemia,
endocrine or cardiac disease).

Yellow Nail Syndrome Yellow nails grow

slow and are curved. May be seen in
AIDS and respiratory syndromes.

Paronychia Local infection.

 COMMON NAIL DISORDERS
Longitudinal ridging parallel ridges
running lengthwise. May be seen in
the elderly and some young people
with no known etiology.

Half-and-Half Nails nails that are half

white on the upper proximal half and
pink on the distal half. May be seen in
chronic renal disease.

Pitting Seen with psoriasis

 ASSESSMENT FINDINGS OF THE HEAD

INSPECTION NORMAL ABNORMAL

HEAD Symmetric, Facial and
Size, Shape, Round, Erect skull bones
Symmetry and in are larger
Midline and thicker
Face Symmetric, Assymetrical
Symmetry, Round, Oval, face
Features, Elongated, Mask like
Movement, Square face
Expression, appearance Sunken eyes
Skin condition Moon
shaped face
 ASSESSMENT FINDINGS OF THE HEAD
PALPATION NORMAL ABNORMAL

Normally hard and Lesions, Lumps may

HEAD
smooth without indicate tumor or
Consistency
deviation trauma

Hard, Thick, and

Elastic and not
TEMPORAL ARTERY tender with
tender
inflammation

No swelling,
Limited ROM,
TEMPOROMANDIBULAR tenderness, and
swelling, tenderness,
JOINT (TMJ) crepitation with
Crepitation
movement
NECK –
composed
of muscles
ligaments
and the
cervical
vertebrae
 ASSESSMENT FINDINGS OF THE NECK

INSPECTION NORMAL ABNORMAL

Neck is symmetric with
With swelling,
Position, symmetry, head centered and
enlarged masses or
lumps and masses without bulging
nodules
masses
Thyroid cartilage,
Movement of the neck cricoid cartilage, Asymetric movement
structure(thyroid gland thyroid gland move or generalized
and thyroid cartilage upward symmetrically enlargement
as the client swallows

C7 is usually visible Prominence or

Cervical vertebrae
and palpable swelling

Smooth and Stiffness, rigidity,

ROM
controlled limited mobility
 ASSESSMENT FINDINGS OF THE NECK
PALPATION NORMAL ABNORMAL
TRACHEA (position) Midline Pulled to one side

THYROID GLAND
Deviated from midline
Hyoid bone
Midline maybe because of
Thyroid cartilage
masses
Cricoid cartilage

No swelling,
CERVICAL Swelling, enlargement
enlargement and
LYMPHNODES and tenderness
tenderness

AUSCULTATE the
thyroid gland if there is
No bruits are A soft, blowing,
enlargement during
auscultated swishing sound
inspection and
palpation
Neck Lymph Nodes
Auscultation