3/23/2022

Skin, Hair, and Nails: Chapter 13

Readings: (approximately 25 pages)

□ p. 219 – 240 Remember to omit infants, children and Pregnant Women (18 pages)
□ p. 245 – 247 Older Adults (3 pages)
OMIT: p. 227 The Dangers of Tanning Salons and the Sun
OMIT: p. 228 Protection From Ticks
OMIT: p. 240 Promoting Heath and Self-Care
□ p. 232 ABCDEs of Abnormal Findings (Pink Highlighted Section on this page)
□ p. 233-236 Abnormal Findings (Pink Highlighted Section on those pages)
□ p. 248 Documentation & Critical Thinking (1 page - Review)
□ p. 259 – 260 Purpuric Lesions (2 pages)
□ p. 270 Late Clubbing (5 lines)

Skin, Hair, and Nails

• Remember that skin and hair distribution are assessments that are
performed throughout all of the body assessments
• Skin has information about body’s circulation, nutritional status,
signs of systemic disease, integument itself (Jarvis, 2019, p.228)
For example –
• On a thorax/lung exam you are examining the skin on the chest
both anteriorly and posteriorly
• When examining the lower extremities, you are again looking for
normal hair distribution, absence of lesions, bruises, moles,
vascular changes etc.
• Findings associated with skin and hair during any assessment
should be documented for that exam

Skin
Epidermis – outermost layer

• Melanin, gives skin & hair their

brown tones, all people have the
same number of melanocytes,
amount varies with genetic,
hormonal, & environmental
influences
• Completely replaced every 4 weeks
• Is avascular, nourished by blood
vessels in the dermis below
• Produces pigmentation

1
 3/23/2022

Dermis - Middle Layer

Skin • Consisting mostly of connective tissue or
collagen (tough, fibrous protein that enables
the skin to resist tearing)
• Resilient elastic tissue that allows the skin to
stretch with body movements
• Contains nerves, sensory receptors, blood
vessels, lymphatic vessels, hair follicles,
sebaceous glands, sweat glands

Subcutaneous - Innermost Layer

• Adipose tissue, made up of lobules of fat cells
• Stores fat for energy, provides insulation for
temperature control, cushioning effect against
external forces
• Gives skin its increased mobility over
structures underneath

Hair
Vellus hair
fine, short, covers most of the body (except palms & soles, dorsa
distal parts of fingers, umbilicus, glans penis, inside the labia)
(Jarvis, 2019, p.219)

Terminal hair
darker, thicker, varies in length, generally found on scalp,
eyebrows, after puberty axillae, pubic area, in men the face and
chest (Jarvis, 2019, p.219-220)

Nails
Nails
• Nails are hard plates of keratin,
growing on the dorsal edges of
the fingers and toes (Jarvis, 2019, p.
220)
• Pink color derived from underlying
nail bed of highly vascular
epithelial cells (Jarvis, 2019, p.221)
• Lunula – white opaque semilunar
area at proximal end of nail (Jarvis,
2019, p.220-221)

2
 3/23/2022

Skin, Hair, and Nails

Sebaceous Glands (Jarvis, 2019, p.220)

• Produce a protective lipid substance (oil like), sebum which is

secreted through the hair follicles to assist skin with moisture
retention
• located all over body in hair follicles excluding soles of feet and
palms of hands
• Most abundant in the scalp, forehead, face, and chin

Skin, Hair, and Nails

Eccrine
Coiled tubules that open directly onto skin surface, produce a dilute saline solution
called sweat.
Widely distributed through the body
Evaporation of sweat reduces body temperature

Apocrine
Produce a thick, milky secretion and open into the hair follicles
Located mainly in axillae, anogenital area, nipples, navel, and are vestigial in humans
Become active during puberty, secretion occurs with emotional and sexual stimulation
Bacterial flora residing on the skin surface react with apocrine sweat to produce a musky
body odour
Function decreases in older adults

Skin, Hair, and Nails

A waterproof, highly resilient covering that has protective and adaptive
properties:

• Protection
• Prevention of penetration
• Perception
• Temperature regulation
• Identification
• Communication
• Wound repair
• Absorption and excretion
• Production of vitamin D

3
 3/23/2022

Developmental Considerations
Older adults
• Slow atrophy of skin structures
• Loss of elasticity, collagen, subcutaneous fat, muscle tone
• Thinning of stratum corneum, allows chemicals easier access to
body
• Decreased sweat and sebaceous glands, leaving skin dry
• Greater risk for heat stroke
• Senile purpura (Jarvis, 2019, p.260)
• Increased risk for skin disease
• Change in hair distribution
• Psychological impact of visible aging

10

Social Determinants of Health

Considerations
• Melanin responsible for various colours and tones observed among
people from culturally diverse backgrounds
• Melanin protects skin against harmful ultraviolet rays
• Areas of skin affected by hormones, may differ among culturally diverse
people:
• Sexual skin areas
• Nipples
• Areola
• Scrotum
• Labia majora
• These areas are darker especially among African and Asian Descent

11

Skin Inspection
• Inspect the skin head to toes – scalp to feet; assess the following:
1. General Pigmentation
• Skin tone
• Freckles, moles, birthmarks
• Pallor, Erythema, Cyanosis, Jaundice
2. Vascularity or Bruising
3. Tattoos
4. Lesions
• Colour, Elevation, Pattern or shape, size, location & distribution on body, any
exudate
• Abnormal Characteristics or pigmented lesions – ABCDE Assessment
• Describe any abnormalities in your documentation
• Normal Findings: Skin has pink undertones, with consistent pigmentation
throughout body and no abnormalities.
• Review Table 13.2 Detecting Colour Changes in Light and Dark Skin

12

4
 3/23/2022

ABCDE’s for Assessment of Melanoma:

Asymmetry
• Does one half look like the other half?
Border irregularity
• Is the border ragged or has poorly
defined margins?
Color variation
• Are there a variety of shades of
different colors?
Diameter
• Is the diameter >6 mm (pencil eraser)?
Elevation or Evolution
• Has the lesion evolved or changed
over time?
• Bleeding, itching, burning, size
change?

13

Skin Palpation
• Temperature – use dorsum of the hand to assess bilateral skin
temperature of arms and legs – normal – warm or cool, should be
equal bilaterally
• Moisture – use palm of hand to assess skin moisture – normal –
consistently moist throughout (look for Diaphoresis & Dehydration)
• Texture – use palmar surface of hand to assess texture of skin –
normal – smooth and even
• Thickness – uniform thickness – may have callouses present
• Edema – imprint your thumbs firmly against the ankle malleolus or
the tibia – normal skin surface resumes smoothness immediately
• If pressure leaves a dent in the skin, “pitting edema” is present
• Its presence is graded on a four-point scale

14

Skin Palpation
• Mobility & Turgor – grasp skin in a fold between thumb and forefinger
(anterior chest below clavicle) normal – skins recoils promptly

• Vascularity or Bruising – press pads of fingers to client's skin –

observe blanching – skin tone should return promptly
• Cherry (senile) angiomas (slightly raised bright red dots) common
in adults over 30
• Ecchymosis (bruising) should be consistent with the trauma
• Presence of any tattoos

• Lesions – palpate lesions for tenderness, mobility, and consistency

• Colour, Elevation, Pattern or shape, Size, Location and
distribution on body, Exudate

15

5
 3/23/2022

Braden Scale
• Is an efficient measurement tool for assisting in objective skin risk
assessment
• It is based on findings and scores from assessing 6 categories and
determining risk according to a final score.

Categories include:
1. Sensory perception – ability to respond to pressure discomfort
2. Moisture – degree to which skin is exposed
3. Activity – degree of physical activity
4. Mobility – ability to change and control body position
5. Nutrition – usual nutritional (food) intake pattern
6. Friction and shear – ability to move and assistance required

16

Braden Scale
• Braden scores are generally done on admission and when clients
condition changes (either deteriorates or improves) during their stay
in a facility.
• Total Scores to determine Risk after completing Braden Scale
• Clients with a score of 18 or less are considered to be at risk for
developing pressure sores. Severity of risk based on Scale is as
follows:

• 15 to 18 = At Risk
• 13 to 14 = Moderate risk
• 10 to 12 = High Risk
• ≤ 9 = Very High Risk

17

Hair Inspection and Palpation

• Wear gloves for palpation if lesions or infestation is suspected or if hygiene is poor.
Colour
• results from melanin production and may vary from pale blond to totally black.
• Normal: greying as early as 30 because of reduced melanin production in follicles or Genetic
factors
Texture
• Scalp hair may be fine or thick and may look straight, curly, or kinky.
• looks shiny, lose shine with use of some beauty products (dyes, rinses, perm materials)
• Note: dull, coarse, or brittle scalp hair
Distribution
• Fine vellus hair coats body, coarser terminal hairs grow: eyebrows, eyelashes, scalp
Lesions
• Separate hair into sections & lift, observing the scalp.
• History of itching, inspect the hair behind the ears and in the occipital areas
• Normal – clean, free of any lesions or pest inhabitants. May have seborrhea (dandruff)

18

6
 3/23/2022

Nails Inspection
Shape & Contour – nail surface normally slightly curved or flat, posterior and lateral nail
folds are smooth and rounded
The Profile Sign – view index finger at profile, note angle of nail base, should be about 160
degrees. Curved nails are a variation of normal with a convex profile
Consistency – surface is smooth, regular, not brittle or splitting. Nail thickness uniform,
firmly adhered to nail bed
Colour – even pink nail bed, dark skinned people may have brown-black pigmented areas
or linear bands or streaks along the nail edge. All people may have white hairline linear
markings

19

Nails Inspection and Palpation

• Nail base is firm on palpation
• Toenails: separate them and note
the smoothness of skin in between
• Check capillary refill:
• press at nail base to blanch
nails, release, note the return
colour – pink colour should
return < 2 seconds for normal
capillary refill
• Compare bilaterally
• Complete on hands and feet
(peripheral circulation)

20

Developmental Older adult

Considerations • Senile lentigines (liver spots)

(Objective Data) • Keratoses: seborrheic or actinic
• Dry skin (xerosis)
• Acrochordons (skin tags)
• Sebaceous hyperplasia
• Thin, parchment-like skin
• Decreased Skin turgor
• Decreased hair growth; changes in
thickness, colour
• Thickened toenails, brittle, or yellow
fingernails

21