Skin, Hair, and Nails

Assessment

Dr. Sameh Elhabashy

 Objectives:

▪ Describe the structure and function of the skin, Nail and hair.
▪ Identify the normal criteria of skin, hair and nail.
▪ Determine the history taken.
▪ Recognize the principals of patient preparation for skin
assessment.
▪ Demonstrate inspection and palpation of the skin, hair and nail.
▪ Describe appropriate documentation of skin assessment.
 Introduction
▪ In any kind of physical assessment, the client’s skin,
hair, and nails are among the most easily observed
characteristics. They also provide clues to the client’s
general health condition.

▪ Skin is the first line of defense. Skin is your body's

largest organ, accounting for around 16% of your body
weight.
Structure of the skin
 Structure of the skin:
• Skin has three layers:

• The epidermis: the outermost layer of skin, provides a

waterproof barrier and creates our skin tone.

• The dermis: lower the epidermis, contains oil glands,

hair follicles, sweat glands and melanocytes, which
hypodermis
produce the (color) pigment melanin.

• The hypodermis: deeper subcutaneous tissue is made

of fat and connective tissue.
Hair
• Hair found over much of the body.
• Root of hair develops within an epidermal cells called
the hair follicle. Shaft of hair projecting above skin
surface.
• There are two general types of hair:

1. Vellus hair is short, pale and fine and is present over

much of the body.
2. Terminal hair (particularly scalp and eyebrows) is
longer, generally darker and rough / thick than the
vellus hair.
Nail
• The nails, located on the distal phalanges of fingers and toes.

• Its hard, transparent plates of keratinized epidermal cells that grow from a root
under the skin fold called cuticle.

• The nail body extends over the entire nail bed and has a pink tinge as a result of
the rich blood supply below.
Nail
• At the base of the nail is the lunula, a paler,
(Half-Moon) shaped area.

• The nails provide protection for the distal

ends of the fingers.

• The angle between the proximal nail fold and

the nail plate is normally less than 180°.
 What is the function of the skin?

• The major function of the skin is to keep the body in homeostasis.

• The skin is a physical barrier that protects the underlying tissues from
microorganisms and trauma.

• Preventing the loss of water and electrolytes from the body.

• Sensing temperature, pain, touch and pressure.

• Regulating body temperature through sweat production and evaporation.

• Vitamin D synthesis.
 History taken.
Past history:
▪ Allergies.
▪ Itchiness.
▪ Psoriasis. (is a chronic autoimmune condition that causes the rapid buildup of skin cells). ‫صدفية‬
▪ Eczema. )is allergic condition where the skin become inflamed, itchy, red(.
▪ Medications (any that cause allergic skin response).
▪ Increased sunlight sensitivity.
Family history: such as acne, skin cancer.
History taken (Cont).
Current History:

• Change in pigmentation.
• Change in mole (size or color).
• Excessive dryness or moisture.
• Pruritus (Itching).
• Excessive bruising (skin injury that cause a discoloration ).
• Rash or lesion.
• Hair loss.
• Change in nails.
History taken (Cont).
Life-style and health practices:

• Environmental or occupational hazards (sun exposure, indoor

tanning, toxic chemicals, insect bites, extreme temperatures).
• Patient-centered care (daily hygiene, use of soaps, cosmetics).
• Spend long periods of time sitting or lying in one position.
• Product use as soaps, lotions, oils, hair spray.
• Foods consumed daily.
• Amount of fluid per day.
Patient preparation for skin assessment.
• Explain to the patient and family the procedure and purposes.

• Conduct the assessment in a private space.

• Make sure the patient is comfortable.

• Wash and sanitize your hands before and after the assessment.

• Wear gloves, and change them as needed.

• Minimize exposure of body parts.

• Ask the patient to remove all clothing and jewelry and to put on agown.
Equipment needed
• Strong direct lighting (natural daylight is ideal to
evaluate skin characteristics)
• Small centimeter ruler
• Penlight
• Gloves
• A wood’s lamp.
Physical Assessment of the Skin

Inspection of the skin

1. Note any distinctive odor.

2. Inspect for generalized color.

3. Inspect for skin integrity.

4. Inspect for lesions

Inspect the Skin:

1- Color:

• General pigmentation. The skin tone is consistent with genetic background

and varies from pinkish to rosy dark tan, or from light to dark brown.

• Dark-skinned people normally have areas of lighter pigmentation on the

palms, nail beds, and lips.

• General pigmentation is darker in sun-exposed areas.

Common (benign) pigmentations also occur:

• Freckles: a small, flat increase of brown melanin

pigment.
• Nevus (mole): a proliferation of melanocytes,
tan-to-brown color, flat or raised.
• Birthmarks: may be dark brown color.
Advise anyone with moles or birthmarks to
perform periodic skin self-examinations.
Abnormal characteristics of pigmented lesions are summarized
with the mnemonic ABCDE:

• Asymmetry of a pigmented lesion.

• Border irregularity.

• Color variation (areas of black, gray, blue, red, white, pink).

• Diameter greater than 6 mm.

• Elevation or evolution.
Abnormal skin color changes
Pallor: Anemia, Decreased Hematocrit Shock, Decreased
perfusion, vasoconstriction.

Cyanosis: Increased amount of unoxygenated hemoglobin -

- Central: Chronic heart & lung disease cause arterial desaturation
- Peripheral: Exposure to cold, anxiety.
Erythema: Hyperemia Increased blood flow through engorged
arterioles: inflammation, fever, alcohol intake. It may be
blenched or not.

Jaundice: Increased serum bilirubin, liver inflammation or

hemolytic disease,
Inspect for skin integrity
• Skin should be intact.

• If skin is not intact, identify the etiology of the skin problem.

• Etiology could be (Pressure – Peripheral vascular (venous or arterial) –

Neuropathic/diabetic – Trauma)

• Check carefully in pressure point areas

(bony prominence area) for skin integrity.

• Skin breakdown is initially noted as

a reddened discoloration.
Stages of Pressure Injury
Inspect for lesions

• Skin lesions are traumatic or pathologic changes of the skin changes

described by their color, shape, cause, or general appearance.

• When a lesion develops on previously normal skin, it is primary.

However, when a lesion changes over time or because of a factor such
as scratching or infection, it is secondary.
Describe the lesion.
• In general, it is important to note the
Distribution of lesions
(anatomical location, distribution,
color, size, exudates, and pattern of
any abnormal skin lesion) also, the
lesion’s borders or edges, as well as
whether the lesion is flat, raised, or
sunken, should be noted.
Stretch marks (striae).
Normal striae (white) Abnormal striae (redness)
Palpation of the skin:
• Temperature
• Moisture
• Texture
• Thickness
• Edema
• Mobility and Turgor
Palpation of Temperature
• Use the backs (dorsal part) of your hands and palpate bilaterally.

• The skin should be warm with equal temperature bilaterally.

• Hypothermia: Generalized coolness may be accompanied with shock

hypotension, or arterial disease. Localized coolness is expected with an
immobilized extremity, as when a limb is in a cast or with an
intravenous infusion.

• Hyperthermia. Generalized hyperthermia occurs with an increased

metabolic rate such as in fever or after heavy exercise. A localized area
feels hyperthermia with trauma, infection, or sunburn.
Palpation of Moisture
• Perspiration (sweat) appears normally on the face, hands, axilla,
and skinfolds in response to activity, a warm environment, or
anxiety.
• Diaphoresis, or profuse perspiration, accompanies an increased
metabolic rate such as occurs in heavy activity or fever.
• Be aware that dark skin may normally look dry and flaky
• Palpation of Texture
Normal skin feels smooth and firm, with an even surface.

• Palpation of Thickness
The epidermis is uniformly thin over most of the body, although
thickened callus areas are normal on palms and soles. A callus is a
circumscribed overgrowth of epidermis and is an adaptation to
excessive pressure.
Palpation of Edema
• Edema is fluid accumulating in the intercellular spaces and normally is not present.
• To check for edema, imprint your thumbs firmly against the ankle malleolus or the tibia.
• Normally the skin surface stays smooth when you lift your thumbs.
• If your pressure leaves a dent in the skin, “pitting” edema is present.

• Its presence is graded on a four-point scale:

Palpation of Mobility and Turgor

• Skin pinches easily and immediately returns to its

original position.

• Mobility and Turgor Pinch up a large fold of skin on the

anterior chest under the clavicle. Mobility is the skin’s
ease of rising, and turgor is its ability to return to place
promptly when released.

• Mobility is decreased when edema is present. Poor

turgor is Evident in severe dehydration or older people.
 Skin Lesions:
Secondary primary
Color changes Color changes Vascular Lesions
Erosion without elevation with elevation
-Telangiectases
Crust Less than If solid If Cyst -Cherry Angioma
Less than 1cm
- Hemangioma
1cm
(Papule) More than Fluid Pus filled
Scale (Macule) Solid & less filled cyst, cyst,
1cm than 5cm
(Plaque) With (Nodule) less than
Ulcer More than edema less than 1cm
1cm
1cm (Wheal) (Pustule)
Solid & (Vesicle)
(Patch) more than
Scar
5cm More than 1cm
(Tumor) more than
1cm (Abscess)
Fissure
(Bulla) If one or more
openings present
(Carbuncle)
• Pustule: A vesicle filled with leukocytes, Pus in
cavity, Elevated.

• Abscess: A localized collection of pus in a

cavity, more than 1 cm in diameter

• Carbuncle: A carbuncle is an a larger abscess

usually with one or more openings;
draining pus onto the skin.
VASCULAR LESIONS
• Telangiectases are permanently dilated, superficial, small blood
vessels that typically form a web like pattern. For example,
spider hemangiomas.

• Cherry angiomas, also known as Campbell De Morgan

spots or senile angiomas, are cherry red papules on the skin
containing an abnormal proliferation of blood vessels.

• Hemangioma: Red, irregular patch caused by capillary dilation

in the dermis of the skin
Scalp and Hair
• The terminal hair is inspected daily, noting the hair’s )quantity, distribution,
and texture) .

• Scalp hair should be resilient (Strong + Flexible) and evenly distributed.

• Hair color varies among persons from pale blond to black according to the
amount of melanin.

• Normal male blading is symmetric.

• Older patients have thinner hair because of a decrease in hair follicles.

Scalp and Hair (Cont.)
• Hirsutism (facial hair on females): is seen in cushing’s
disease and after menopause.
• (Alopecia) refers to hair loss and can be diffuse, patchy, or
complete, may be seen in scalp infections, chemotherapy,
hormonal disorders, or radiation therapy.
• Patchy gray areas color may occur with nutritional
deficiencies.
• The scalp and body hair are inspected regularly for flaking,
sores, or lice.
Assessment of Nails
• The nail bed is very vascular and is an excellent location for
assessing the adequacy of the patient’s peripheral circulation.

• Nails are hard and basically immobile, smooth, regular, curved.

• Pink tones. Some longitudinal ridging is normal.

• Inspect for grooming and cleanliness, color and markings, shape,

texture, Palpate for consistency, capillary refill.
 Assessment of Nails (Cont.)
• Dirty, broken or jagged fingernails may be seen with poor
hygiene or depression.

• Splinter hemorrhages may be caused by trauma

• Paronychia is a skin infection that develops around the nail.

• When the angle of the nail is 180 degrees or greater, clubbing

is present. Clubbing is attributed to chronic hypoxemia.

• Terry's nails is appear white with a characteristic "ground

glass" appearance without any lunula, can be seen in chronic
disease states, such as cirrhosis, heart failure
Any Question,,,,