HA – SL – NOTES - Hair develops within a Subcutaneous Tissue sheath of

ASSESSMENT OF THE SKIN, HAIR & NAILS epidermal cells called the hair follicle
STRUCTURE OF THE SKIN Two general types of hair:
1. Vellus hair (peach fuzz)
- is short, pale, fine, and present over much of the body.
2. Terminal hair (particularly scalp and eyebrows)
- is longer, generally darker, and coarser than vellus hair.
COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY
Nonjudgmental and Sensitive Approach
- is needed if the client has abnormalities that may be
associated with poor hygiene or unhealthful behaviors.
- Some skin disorders might be highly visible and potentially
damaging to the person’s body image and self-concept

FUNCTIONS OF THE SKIN

 Perceiving touch, presssure, temperature, pain via nerve
endings
 Protection
 Body temperature regulation
 Repairs surface wounds
 Synthesizing Vit. D
 Identification
STRUCTURE OF NAIL

nails
- located on the distal phalanges of fingers and toes, are
hard, transparent plates of keratinized epidermal cells that
grow from the cuticle
nail body
- extends over the entire nail bed and has a pink tinge as a
result of blood vessels underneath.
lunula
- is a crescent-shaped area located at the base of the nail.
STRUCTURE OF HAIR

Hair
- consists of layers of keratinized cells, found over much of
the body except for the lips, nipples, soles of the feet,
palms of the hands, labia minora, and penis.
 Cyanosis
- cause white skin to appear blue-tinged, especially in the
perioral, nail bed, and conjunctival areas. Dark s may
appear blue, dull, and lifeless in the same areas.
Jaundice
- in light and dark-skinned people is characterized by yellow
skin tones, from pale to pumpkin, particularly in the sclera,
oral mucosa, palms, and soles.
COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION Acanthosis Nigricans
Preparing the Client - is roughening and darkening of skin in localized areas,
 Ask the client to remove all clothing and jewelry and put on an especially the posterior neck (Acanthosis Nigrans, 2010)
examination gown. In addition, ask the client to remove nail
enamel, artificial nails, wigs, toupees, or hairpieces as
appropriate
 During the skin examination, ensure privacy by exposing only
the body part being examined.
 Make sure that the room is a comfortable temperature.
 Keep the room door closed or the bed curtain drawn to
provide privacy as necessary
 Explain what you are going to do, and answer any questions
the client may have.
 Wear gloves when palpating any lesions because you may be
exposed to drainage.
Equipment ASSESMENT PROCEDURE
 Examination light - Note any odor emanating from the skin.
 Penlight NORMAL FINDINGS
 Mirror for client’s self-examination of skin - client has slight or no odor of perspiration, depending on
 Magnifying glass activity.
 Centimeter ruler ABNORMAL FINDINGS
 Gloves - strong odor of perspiration or foul odor may indicate
 Wood’s light disorder of sweat glands.
 Examination gown or drape - poor hygiene practices may indicate a need for client
REMEMBER THESE KEY POINTS!!! teaching or assistance with activities of daily living.
 Inspect skin color, temperature, moisture, texture. - especially the posterior neck (Acanthosis Nigrans, 2010)
 Check skin integrity. ASSESMENT PROCEDURE
 Be alert for skin lesions. - inspect for color variations.
SKIN - localized parts of the body, noting any color variation.
ASSESSMENT PROCEDURE Cultural Considerations
Inspect General Skin Coloration - pale or light-skinned clients have darker pigment around
- the amount of pigment in the skin accounts for the nipples, lips, and genitelia.
intensity of color as well as hue. NORMAL FINDINGS
Cultural Considerations - common variations include suntanned areas, freckles, or
- individuals with fair complexions are at an increased risk white patches know as vitiligo
for skin cancer. - variation is due to different amounts of melanin in certain
NORMAL FINDINGS areas.
- inspection reveals evenly colored skin tones without - freckle-like or dark streaks of pigmentation are also
unusual or prominent discoloration. common in the sclera and nail beds of dark-skinned clients.
Cultural Considerations ABNORMAL FINDINGS
- small amounts of melanin are common in pale or light skin, Rashes
while large amounts of melanin are common in olive and - reddish, in light-skinned people
darker skins. Carotene accounts for a yellow cast. - darkened, in dark-skinned people
Older Adult Considerations - butterfly rush, called Malar rash, across the bridge of the
- skin becomes pale due to decreased melanin production nose and cheeks.
and decreased dermal vascularity.
ABNORMAL FINDINGS
Pallor (Loss of color)
- seen in arterial insufficiency, decreased blood supply, and
anemia.
- Pallid tones vary from pale to ashen without underlying
pink.
ASSESMENT PROCEDURE
Check skin integrity
- pay attention to pressure point areas.
NORMAL FINDINGS
- skin is intact, and there are no reddened areas.
ABNORMAL FINDINGS
- skin breakdown is initially noted as a reddened area on the
skin that may progress to serious and painful pressure
ulcers.
ASSESMENT PROCEDURE
inspect for lesions
- observe the skin surface to detect abnormalities
if found a lesion
- note color, shape, and size of lesion.
- for very small lesions, use magnifying glass to note these
characteristics.
- note location, distribution, and configuration.
- measure the lesion with a centimeter ruler.
NORMAL FINDINGS
- skin is smooth, without lesions,
- stretch mark (striae), healed scar, freckles, moles, or
birthmarks are common findings.
- freckles or moles may be scattered over the skin in no
particular pattern.
ABNORMAL FINDINGS
- lesions may indicate local or systemic problems.
Primary lesions
- arise from normal skin due to irritation or disease.
Secondary lesions
- arise from changes in primary lesions.
Vascular lesion reddish
- bluish lesions, are seen with bleeding, venous pressure,
aging, liver disease, or pregnancy.
ASSESMENT PROCEDURE
- palpate skin to assess texture.
- use palmar surface of your three middle fingers to palpate
skin texture.
- palpate to assess thickness
- if lesions are noted when assessing skin thickness, put
gloves on and palpate the lesion between the thumbs and
index finger for size, mobility, consistency, and tenderness.
- observe for drainage or other characteristic.
NORMAL FINDINGS
- skin is smooth and even.
- skin is normally thin but calluses (rough, thick sections of
epidermis) are common on areas of the body that are
exposed to constant pressure.
- no lesions palpated.
ABNORMAL FINDINGS
- rough, flaky, dry skin is seen in hypothyroidism.
- obese clients often report dry, itchy skin.
- very thin skin may be seen in clients with arterial
insufficiency or in those on steroid therapy.
- infected lesions may be tender to palpate.
ASSESMENT PROCEDURE
- palpate to assess moisture
- check under skin folds and in unexposed areas.
Clinical Tip
- nurses believe that using the dorsal surfaces of the hands
to assess moisture leads to a more accurate result
NORMAL FINDINGS
- skin surface varies from moist to dry depending on the
area assessed.
- recent activity or a warm environment may cause
increased moisture.
Older Adult Considerations
- may feel dryer than a younger client’s skin because sebum
production decreases with age.
ABNORMAL FINDINGS
- increased moisture or diaphoresis (profuse sweating) may
occur in conditions such as fever or hyperthyroidism.
- decreased moisture occurs with dehydration or
hypothyroidism
ASSESMENT PROCEDURE
- palpate to assess temperature
- use dorsal surfaces of your hands to palpate the skin.
NORMAL FINDINGS
- skin is normally a warm temperature.
ABNORMAL FINDINGS
- cold skin may accompany shock or hypotension.
- Cool skin may accompany arterial disease.
- Very warm skin may indicate a febrile state or
hyperthyroidism
ASSESMENT PROCEDURE
Palpate to assess mobility and turgor.
- Ask the client to lie down.
- Using two fingers, gently pinch the skin over the clavicle.
- Mobility refers to how easily the skin can be pinched.
- Turgor refers to the skin’s elasticity and how quickly the
skin returns to its original shape after being pinched.
NORMAL FINDINGS
- Normally, the skin is mobile, with elasticity and return to original
shape quickly
ABNORMAL FINDINGS
- Decreased mobility is seen with edema.
- Decreased turgor (a slow return of the skin to Its normal
state taking longer than 30 seconds) Is seen in
dehydration.
ASSESMENT PROCEDURE
- Palpate to detect edema
- Use your thumbs to press down on the skin of the feet or
ankles to check for edema (swelling related to
accumulation of fluid in the tissue).
NORMAL FINDINGS
- Skin rebounds and does not remain indented when
pressure is released
ABNORMAL FINDINGS
- indentations on the skin may vary from slight to great and
may be in one area or all over the body

NAIL
SCALP AND HAIR
 RECORDING YOUR FINDINGS
Note that initially you may use sentences to describe your findings;
later you will use phrases. The style below contains phrases
appropriate for most write-ups.
 “Color pink. Skin warm and moist. Nails without clubbing or
cyanosis. No suspicious nevi. No rash, petechiae, or
ecchymoses.”
 “Marked facial pallor, with circumoral cyanosis. Palms cold and
moist. Cyanosis in nailbeds of fingers and toes. One raised
blue-black nevus, 1 × 2 cm, with irregular border on right
forearm. No rash.”
 Head and Neck Assessment OTHER NECK STUCTURES
HEAD/SKULL STRUCTURE

NECK STRUCTURE

COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY

PAST HEALTH HISTORY

FAMILY HEALTH HISTORY

LIFESTYLE HEALTH PRACTICES

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

Preparing the client:
 Instructing him or her to remove any wig, hat, hair ornaments,
pins, rubber bands, jewelry, and head or neck scarves.
 Ask the client to sit in an upright position with the back and
shoulders held back and straight.
 Explain the importance of remaining still during most of the
inspection and palpation of the head and neck.
 explain the need for the client to move and bend the neck for
examination of muscles and for palpation of the thyroid gland.
 Be aware that some clients may be anxious as you palpate the
neck for lymph nodes, especially if they have a history of
cancer that caused lymph node enlargement. Tell the client
what you are doing and share your assessment findings.
EQUIPMENTS:
 Small cup of water
 Stethoscope