Bulacan State University

City of Malolos, Bulacan

COLLEGE OF NURSING

NCM 101-A : HEALTH ASSESSMENT

Nursing Assessment of Physical Systems:

SKIN, HAIR and NAILS

Anatomy
I. Skin and its Layers

A. Epidermis
▪ In order, from outermost to innermost, comes with stratum corneum, stratum
lucidum, stratum granulosum and stratum germinativum.
▪ Stratum germinativum (basal cell layer)
✓ Mitosis occurs here
✓ Contains melanocytes, producing melanin
▪ Stratum corneum
✓ As cells rise, they die and their cytoplasm is converted to keratin, which
has a rough, horny texture
✓ This layer undergoes constant shedding

RHEALEEN VIRAY-VICEDO, RN, MAN

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Instructor I
 B. Dermis
▪ Mostly connective tissue, primarily collagen
▪ Provides support and nourishment of epidermis
▪ Blood vessels, nerves, muscle, sweat glands, sebaceous glands, hair follicles
o Sebaceous glands
✓ Produce sebum through hair follicles, which make skin oily. Prevent
water loss.
o Sweat glands
✓ Eccrine – smaller, coiled tubules which open to skin surface and
located over the entire skin.
✓ Apocrine – larger, open to hair follicles. Located mainly in axillae,
areolae of the breasts and genital area which are relatively small and
nonfunctional until puberty. Produce thick secretions, which react
with bacteria on skin surface to produce body odor

C. Subcutaneous Layer (Hypodermis)

▪ Consists mostly of fat
▪ Provides protection, insulation, and caloric source
II. Hair
▪ Composed of keratin
▪ Can be fine (vellus hair) or darker and thicker (terminal hair)
III. Nails
▪ Composed of keratin
▪ Clear with highly vascular bed of epithelial cells underneath

Developmental Considerations
I. Infants
• Lanugo – fine soft hair present at birth
• Skin is thinner, less fat – more prone to
dehydration and hypothermia

II. Pregnancy
• Linea nigra – line down
midline of abdomen
• Chloasma – face of
pregnancy
• Striae gravidarum –
stretch marks

RHEALEEN VIRAY-VICEDO, RN, MAN

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Instructor I
 III. Aging
▪ Stratum corneum thins, loss of collagen, elastin, and fat, decrease of sebaceous
and sweat glands,
▪ More prone to dehydration and hypothermia

History
o History of skin disease
• What was it? How was it treated?
• Does it run in the family?
o Significant familial predispositions – allergies, hay fever, psoriasis, eczema,
acne
▪ Any know allergies?
▪ Any tattoos or birthmarks?
• Use of nonsterile equipment for tattoos increases risk of Hep C
o Change in pigmentation
▪ Might suggest systemic illness (jaundice)
o Change in a mole
o Pruritus
• Any dryness? Is it seasonal?
o Xerosis – dry
o Seborrhea - oily
o Excessive bruising
• Consider abuse
• Frequent minor trauma may be sign of alcohol abuse
o Rash or lesion
• Onset
• Location
• Spread
• Character or quality
• Duration
• Associative factors – pets, co-worker?
• Alleviating and aggravating factors – what have you tried to do?
• Patient’s perception - what do you think it is?
o Medications
• Prescription and over-the-counter
• May indicate allergy to medication
o Hair loss or growth
• Gradual or sudden?
• Hirsutism – unusual growth
o Change in nails
o Exposure to hazards
• May be environmental or occupational
▪ Bitten by bee, tick, mosquito?
▪ Exposure to plants or animals?
o Self care
• What cosmetics, soaps, chemicals?
▪ Possible allergies

Physical Examination - Color

• General pigmentation – should be even throughout
• Benign pigmented areas
▪ Freckles (macules) on sun exposed skin (A macule is a flat, distinct, discolored
area of skin less than 1 centimeter (cm) wide. It doesn't involve any change in
the thickness or texture of the skin.)
▪ Nevi (moles)
o Junctional nevi – macular only

RHEALEEN VIRAY-VICEDO, RN, MAN

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Instructor I
 o Compound nevi – macular and papular
o Dysplastic – precancerous

Dysplastic Nevus
o Birthmarks
• Vitiligo – absence of melanin in patchy areas

Changes in Color in Light Skinned People

› Pallor
o Pale, white color caused by decrease of blood flow (vasoconstriction) or decrease in
hemoglobin
o Brown skinned people will be more yellow. Black skinned people will be more gray
o Palpebral conjunctiva and nail beds should be observed
o Shock, anemia
› Erythema
o Redness due to increased blood flow (vasodilation)
o If fever suspected, check skin for warmth. If edema, check skin for tightness
o May be caused by fever, inflammatory process, emotions, CO poisoning
› Cyanosis
o Bluish, purplish hue due to decreased perfusion of tissues
o Darker skinned people have normal bluish tone on lips
o Palms, but not clearly evident, other clinical signs should be observed
o May be caused by hypoxemia due to heart failure, shock, chronic
bronchitis
› Jaundice
o Yellow, orange hue due to jaundice (increased bilirubin in blood)
o Hard and soft palate must be observed in addition to sclera of eyes
o Dark urine also present
o Due to liver problems such as hepatitis, cirrhosis
› Temperature
o Check skin with dorsa of hands
▪ Hyperthyroidism may cause increase of temp
› Moisture
o Diaphoresis may occur during fever or exercise
o Dehydration can be observed by dry mucous membranes in mouth and cracked skin
› Mobility and Turgor
o Mobility is ease of skin rising when pinched. Turgor
is returning back to its place
o Slow turgor can be indicative of dehydration.
“Tenting” if severe dehydration.
› Lesions
o A lesion is any traumatic or pathological change in
skin
o Roll nodule gently between fingers to assess depth
o Ultraviolet light is used if fungal infection suspected
(Wood’s light)*****

RHEALEEN VIRAY-VICEDO, RN, MAN

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Instructor I
Edema
➢ The presence of excess interstitial fluid; an area that appears swollen, shiny and taut and tends
to blanch the skin color or, if accompanied by inflammation, may redden the skin. It may also
described as pitting or non-pitting edema.
➢ Scale for Pitting Edema:

Pressure Ulcers
➢ also known as pressure sores or bedsores, are
injuries to the skin and underlying tissue, primarily
caused by prolonged pressure on the skin.
➢ They can happen to anyone, but usually affect
people confined to bed or who sit in a chair or
wheelchair for long periods of time.

Nursing Responsibility
o Use repositioning schedules (every 15 minutes
when on chair or every 2 hours when on bed)
o Use pressure mattress or chair cushion
o Use lifting devices as directed to reduce shear (trapeze bar for patients, or lifts for family, if
necessary)
o Use positioning with pillows or wedges to avoid bony prominence contact with surfaces and to
maintain body alignment
o For those who are bedbound, avoid elevating the head of bed beyond 30 degrees except for
brief periods

RHEALEEN VIRAY-VICEDO, RN, MAN

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Instructor I