Chapter 14

Assessing Skin, Hair, and Nails

Structure and Function of Skin

• The skin is the largest organ of the body.

• The skin is a physical barrier that protects the underlying
tissues and structures from microorganisms, physical
trauma, ultraviolet radiation, and dehydration.
• Vital role in temperature maintenance, fluid and
electrolyte balance, absorption, excretion, sensation,
immunity, and vitamin D synthesis.

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Skin, Hair, and Nails

• Skin: epidermis, dermis, sebaceous glands, sweat

glands, subcutaneous layers
• Hair: vellus, terminal
• Nails: nail body, lunula

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Question

Is the following statement true or false?

Sebum has some fungicidal and bactericidal effects.

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Answer

True.
Sebum has some fungicidal and bactericidal effects.

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Question

Is the following statement true or false?

Asians and Native Americans have strong body odor.

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Answer

False.
Asians and Native Americans have mild to no body odor
because of decreased sweat production. Caucasians and
African Americans tend to have a strong body odor.

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Skin Cancer

• Most common of cancers

• Three types: melanoma, basal cell carcinoma, squamous
cell carcinoma
• Asians are less susceptible

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Risk Factors of Skin Cancer

• Sun exposure
• Nonsolar sources of ultraviolet radiation
• Medical therapies
• Family history and genetic susceptibility
• Moles
• Pigmentation irregularities
• Fair skin that burns and freckles easily; light hair
• Age
• Actinic keratosis

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Risk Factors of Skin Cancer (cont.)

• Male gender
• Chemical exposure
• Human papillomavirus
• Xeroderma pigmentosum
• Long-term skin inflammation or injury
• Alcohol intake; smoking
• Inadequate niacin in diet
• Bowen disease (scaly or thickened patch) (SCC)
• Depressed immune system

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Risk Reduction in Skin Cancer

• Reduce skin exposure.

• Always use sunscreen when sun exposure is anticipated.
• Wear long-sleeve shirts and wide-brimmed hats.
• Avoid sunburns.
• Wear sunglasses that wrap around.
• Understand the link between sun exposure and skin cancer and
the accumulating effects of sun exposure on developing
cancers.
• Have annual skin cancer screenings.

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Risk Reduction in Skin Cancer (cont.)

• Ensure that diet is adequate in vitamin B3 (niacin).

• Examine the skin for suspected lesions using the ABCDE
mnemonic to assess suspicious lesions:
– Asymmetry
– Border
– Color
– Diameter
– Evolution (changes over time)

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Question

Which skin disorder may be caused by exposure to the

sun?
A. Acne
B. Cancer
C. Vitiligo
D. Warts

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Answer

B. Cancer.
Skin cancer may be caused by exposure to the sun. Acne,
vitiligo, and warts are not caused by sun exposure.

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Cultural Variations in Skin Cancer

• Asians are less susceptible to skin cancer

• African Americans, Asians, and Hispanics are
susceptible to melanoma
• Asian Americans and African Americans tend to
present with more advanced disease at diagnosis

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Risk Factors for Methicillin-Resistant
Staphylococcus aureus

• Assess for hospital-acquired MRSA risk factors:

– Having an invasive medical device
– Residing in a long-term care facility
– Presence of an MRSA-positive person in the facility

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Risk Factors for Methicillin-Resistant
Staphylococcus aureus (cont.)

• Assess for community-acquired MRSA risk factors:

– Participating in contact sports
– Sharing personal items such as towels or razors
– Suppression of immune system function (e.g., HIV,
cancer, or chemotherapy)
– Residing in unsanitary or crowded living conditions
(e.g., dormitories or military barracks)

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Risk Factors for Methicillin-Resistant
Staphylococcus aureus (cont.)

– Working in the health care industry

– Receiving antibiotics within the past 3 to 6 months
– Young or advanced age
– Men having sex with men
– Hemodialysis

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Measures to Reduce Risk Factors for
Methicillin-Resistant Staphylococcus aureus

• Keep wounds covered.

• Do not share personal items.
• Avoid unsanitary or unsafe nail care practices.
• If treatment has been started, do not stop until recovery is complete.
• Use universal precautions when touching others to avoid contact with
contaminated body fluids. Wash your hands.
• Clean sports equipment between uses to avoid spread of infection.
• Wash clothes, sheets, towels, razors, and other personal items before
and after use.
• Clean hands often.

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Nursing History: Present Health Concern

• Body odor problems

• Skin problems (rashes, lesions, dryness, oiliness,
drainage, bruising, swelling, pigmentation)
• Changes in lesion appearance
• Feeling changes (pain, pressure, itch, tingling)
• Hair loss or changes
• Nail changes

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Nursing History (cont.)

• Personal health history

• Family history
• Lifestyle and health practices
– Exposure to sun or chemicals
– Daily care of skin, hair, and nails
– Usual diet and exercise patterns

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Client Preparation

• Ask the client to remove all clothing and jewelry.

• Have the client sit comfortably.
• Ensure privacy.
• Maintain comfortable room temperature.

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Equipment for Skin, Hair, and Nail
Assessment

• Gloves
• Examination light and penlight
• Mirror for client’s self-examination of skin
• Magnifying glass
• Centimeter ruler
• Wood light
• Examination gown or drape
• Assessment Tool 14-1, Braden Scale For Predicting Pressure Sore Risk
• Assessment Tool 14-2, PUSH Tool to Measure Pressure Ulcer Healing

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Skin Assessment: Inspection

• Note any distinctive odor

• Generalized color variations
• Skin breakdown
• Primary, secondary, or vascular lesions

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Skin Assessment: Palpation

• Lesions
• Texture
• Temperature and moisture
• Thickness of skin
• Mobility and turgor
• Edema

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Pressure Ulcer Risk Factors

• Perception
• Mobility
• Moisture
• Nutrition
• Friction or shear against surfaces
• Tissue tolerance decreased

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Pressure Ulcer Risk Reduction

• Inspect the skin at least daily and more often if at

greater risk using risk assessment tool (such as Braden
Scale or PUSH tool) and keep flow chart to document.
• Bathe with mild soap or other agent; limit friction; use
warm, not hot, water; set bath schedule that is
individualized.
• For dry skin: use moisturizers; avoid low humidity and
cold air.
• Avoid vigorous massage.

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Pressure Ulcer Risk Reduction (cont.)

• Use careful positioning, turning, and transferring

techniques to avoid shear and friction or prolonged
pressure on any point.
• Refer nutritional supplementation needs to primary care
provider or dietitian, especially if protein deficient.
• Refer incontinence condition to primary care provider.
• Use incontinence skin cleansing methods as needed:
frequency and methods of cleaning, avoiding dryness
with protective barrier products.

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Scalp and Hair

• Inspection and palpation

– General color and condition, cleanliness, dryness or
oiliness, parasites, and lesions
– Amount and distribution of scalp, body, axillae, and
pubic hair

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Nail Assessment

• Nails
– Inspection: Nail grooming and cleanliness, nail color
and markings, shape of nails
– Palpation: Assess texture and consistency, capillary
refill

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Nails Risk Factors

• Nails in moist environment, especially walking in damp public

locales or continuously wearing closed shoes; excessive
perspiration
• Nail injury, trauma, or irritation
• Repeated irritation (especially water, detergents)
• Immune system disorders such as diabetes mellitus and AIDS
or on immunosuppressive medications
• Skin conditions such as psoriasis or lichen
• Some trades or professions
• Contagion from one digit to another or one person to another
• Possibly family predisposition

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Nails Risk Reduction Tips

• Wear leather shoes except for sports.

• Avoid wearing closed shoes all the time.
• Wear socks that wick away moisture.
• Avoid going barefoot in damp public areas.
• Avoid too much perspiration or water (wear gloves for
hands).
• Avoid trauma to nails.
• Avoid unsanitary or unsafe nail care practices.
• If treatment is started, do not stop until recovery is
complete.

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Physical Assessment

• Capillary refill assessment procedure

• Hair color and texture
– Individuals of African American descent often have
very dry scalps and dry, fragile hair.

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Self-Assessment of Skin, Hair, Nails

• Refer to Box 14-1, Self-Assessment: How to

Examine Your Own Skin

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Normal and Abnormal Findings

• Share outcomes of skin, hair, and nails assessment with

peers

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Pressure Ulcer Stages

• Stage I
• Stage II
• Stage III
• Stage IV
• Unstagable

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Primary Skin Lesions

• Macule and patch

• Papule and plaque
• Nodule and tumor
• Vesicle and bulla
• Wheal
• Pustule
• Cyst

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Secondary Skin Lesions

• Erosion
• Ulcer
• Scar
• Fissure

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Vascular Skin Lesions

• Petechia
• Ecchymosis
• Hematoma
• Cherry angioma
• Spider angioma
• Telangiectasis

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Common Nail Disorders

• Longitudinal ridging
• Half-and-half nails
• Pitting
• Koilonychia
• Yellow nail syndrome
• Paronychia

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Common Changes in Aging Skin, Hair, and
Nails

• Skin
– Pale
– Skin lesions
– Dry
– Loses turgor
• Hair: Thinner
• Nails: Thickened, yellow, brittle

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Validating and Documenting Findings

• Health promotion diagnoses

• Risk diagnoses
• Actual diagnoses
• Collaborative problems
• Medical problems

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