Assessment of

Skin, Hair, & Nails

HEALTH ASSESSMENT
Collecting
Subjective Data:
SKIN
HISTORY OF PRESENT
HEALTH CONCERN: SKIN
 Are you experiencing any current skin problems
such as rashes, lesions, dryness, oiliness,
drainage, bruising, swelling, or increased
pigmentation? What aggravates the problem?
What relieves it?
 Describe any birthmarks or moles you now have.
Have any of them changed color, size, or shape?
HISTORY OF PRESENT
HEALTH CONCERN: SKIN
 Have you noticed any change in your ability to feel
pain, pressure, light touch, or temperature changes?
Are you experiencing any pain, itching, tingling, or
numbness?
 Do you have trouble controlling body odor? How
much do you perspire?
 Do you have any body piercings or tattoos?
 Have you had any hair HISTORY
loss or change in the OF
condition of your hair?
Describe.
PRESENT
 Have you had any change HEALTH
in the condition or CONCERN:
appearance of your nails?
Describe.
HAIRS AND
NAILS
PAST HEALTH HISTORY
 Describe any previous problems with skin, hair, or
nails, including any treatment or surgery and its
effectiveness.
 Have you ever had any allergic skin reactions to
food, medications, plants, or other environmental
substances?
 Have you had a fever, nausea, vomiting,
gastrointestinal (GI), or respiratory problems?
FAMILY HISTORY
 Has anyone in your family had a recent illness,
rash, or other skin problem or allergy? Describe.
 Has anyone in your family had skin cancer?
 Do you have a family history of keloids?
LIFESTYLE AND HEALTH
PRACTICES
 Do you spend long periods of time sitting or lying
in one position?
 Have you had any exposure to extreme
temperatures?
 Do skin problems limit any of your normal
activities?
Collecting
Objective Data:
SKIN
  Ask the client to remove all
clothing and jewelry and put on
an examination gown
 Ask the client to remove nail
enamel, artificial nails, wigs,
Preparing toupees, or hairpieces as
appropriate.
the Client  Have the client sit comfortably on
the examination table or bed for
the beginning of the examination.
 Ensure privacy by exposing only
the body part being examined.
Preparing the Client

MAKE SURE THAT THE IF AVAILABLE, EXPLAIN WHAT YOU WEAR GLOVES WHEN
ROOM IS A SUNLIGHT IS BEST FOR ARE GOING TO DO, AND PALPATING ANY
COMFORTABLE INSPECTING THE SKIN. ANSWER ANY LESIONS
TEMPERATURE. QUESTIONS THE CLIENT
MAY HAVE.
Equipment
1. Examination light
2. Penlight
3. Mirror for client’s self-examination
of skin
4. Magnifying glass
5. Centimeter ruler
6. Gloves
7. Wood’s light
8. Examination gown or drape
9. BRADEN SCALE for Predicting
Pressure Sore Risk
10. PRESSURE ULCER SCALE FOR
HEALING (PUSH) tool to measure
pressure ulcer healing
Inspection
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect general evenly colored -Pallor

skin coloration skin -Cyanosis
tones without (Central vs
unusual or peripheral)
prominent -Acanthosis
discolorations. nigricans
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

While inspecting skin Client has slight or no A strong odor of

coloration, note odor of perspiration, perspiration or foul
any odors emanating depending on activity. odor may indicate
from the skin. disorder of sweat
glands.

Poor hygiene
practices may indicate
a need for client
teaching or assistance
with activities of
daily living.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect for color some clients have -rashes, such

variations suntanned areas, as the reddish (in
freckles, or white light-skinned people)
patches known as or darkened (in dark-
vitiligo skinned people)
butterfly rash across
the bridge of the nose
and cheeks

Albinism

Erythema- seen in
inflammation, allergic
reactions, or trauma.
PROCEDURE
Check skin integrity,
especially carefully
in pressure point areas
Use the Braden Scale to
predict pressure sore risk.
If any skin breakdown is
noted, use the PUSH tool
to document the degree of
skin breakdown.
NORMAL FINDINGS ABNORMAL FINDINGS
Skin is intact, and there Skin breakdown is
are no reddened initially noted as a
areas. reddened area on the skin
that may progress to
serious and painful
pressure ulcers
Depending on the color of
the client’s skin, reddened
areas may not be
prominent,
although the skin may feel
warmer in the area of
breakdown than
elsewhere.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect for lesions. Smooth, without lesions. Primary lesions arise from
Stretch marks normal skin due to irritation
Observe the skin (striae), healed scars, or disease.
surface to detect freckles, moles, or
abnormalities. Note birthmarks are common Secondary lesions arise from
findings changes in primary lesions.
color, shape, and size
of lesion. For very Vascular lesions, reddish-
small lesions, use a bluish lesions, are seen
with bleeding, venous
magnifying glass to pressure, aging, liver disease,
note these or pregnancy.
characteristics.
Skin cancer lesions can be
either primary or secondary
lesions and are classified as
squamous cell carcinoma,
basal cell carcinoma,
or malignant melanoma
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

If you suspect a Lesion does not Blue-green

fungus, shine a fluoresce. fluorescence indicates
Wood’s fungal
light on the lesion. infection.

If you observe a Normal lesions may distribution may

lesion, note its be moles, freckles, be diffuse, localized
to one area, or in sun-
location, birthmarks, and the exposed areas.
distribution, and like. They may be Configuration may be
configuration. scattered over the discrete (separate and
Measure skin in no particular distinct), grouped
the lesion with a pattern. (clustered), confluent
(merged), linear (in a
centimeter ruler. line), annular and arciform
(circular or arcing), or
zosteriform
(linear along a nerve
route).
Palpation
PROCEDURE
Palpate skin to assess
texture. Use the
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 thumb and finger.
Observe for
drainage or other
characteristics.
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.
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.
PROCEDURE
Palpate to assess
moisture. Check
under skin folds and in
unexposed areas.
➤ Clinical Tip • Some
nurses believe that using the
dorsal surfaces of the
hands to assess moisture
leads to a more accurate
result.
Palpate to assess
temperature. Use the
dorsal surfaces of your
hands to palpate
the skin
NORMAL FINDINGS ABNORMAL FINDINGS
Skin surfaces vary from Increased moisture or
moist to dry depending diaphoresis (profuse
on the area assessed. sweating) may occur in
Recent activity or a conditions such as fever
warm environment may or hyperthyroidism.
cause increased Decreased moisture
moisture. occurs with dehydration
or hypothyroidism.
Skin is normally a warm Cold skin may accompany
temperature. shock or hypotension.
Cool skin may accompany
arterial disease. Very warm
skin may indicate
a febrile state or
hyperthyroidism.
PROCEDURE
Palpate to assess
mobility and turgor.
Ask the client to lie down.
Using two fingers,
gently pinch the skin on the
sternum or under 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 ABNORMAL FINDINGS
Skin pinches easily and Decreased mobility is
immediately returns
to its original position.
seen with edema.
The older client’s skin loses
its turgor because of a Decreased turgor (a
decrease slow return of the skin to its
in elasticity and collagen normal state taking longer
fibers. than 30 seconds) is seen in
Sagging or wrinkled skin dehydration
appears in the
facial, breast, and scrotal
areas.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Palpate to detect Skin rebounds and does not

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).
remain indented
Indentations on the
when pressure is released. skin may vary from
slight to great and may be in
one area or
all over the body
Scalp and Hair

INSPECTIONS AND PALPATION

PROCEDURE
Have the client remove any
hair clips,
hair pins, or wigs. Then
inspect the
scalp and hair for general
color and
condition.
At 1-inch intervals,
separate the hair
from the scalp and inspect
and palpate
the hair and scalp for
cleanliness, dryness
or oiliness, parasites, and
lesions
(Fig. 13-9). Wear gloves if
lesions are
suspected or if hygiene is
poor.
NORMAL FINDINGS
Natural hair color, as
opposed to chemically
colored hair, varies among
clients
from pale blond to black to
gray or white.
The color is determined by
the amount of
melanin present.
Scalp is clean and dry. Sparse
dandruff
may be visible. Hair is
smooth and firm,
somewhat elastic. However,
as people
age, hair feels coarser and
drier.
Individuals of black African
descent
often have very dry scalps
and dry, fragile hair, which
ABNORMAL FINDINGS
Nutritional deficiencies may
cause patchy gray hair in
some clients. Severe
malnutrition in
African-American children
may cause
a copper-red hair color
(Andrews &
Boyle, 1999).
Excessive scaliness may
indicate dermatitis.
Raised lesions may indicate
infections
or tumor growth. Dull, dry
hair
may be seen with
hypothyroidism and
malnutrition. Poor hygiene
may indicate
a need for client teaching or
assistance
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect amount and Varying amounts of terminal Excessive generalized hair

distribution of hair cover loss may
scalp, body, axillae, and the scalp, axillary, body, and occur with infection,
pubic hair. pubic areas nutritional deficiencies,
Look for unusual growth according to normal gender hormonal disorders, thyroid
elsewhere on distribution. or liver disease, drug toxicity,
the body. Fine vellus hair covers the hepatic
entire body or renal failure (Sabbagh,
except for the soles, palms, 1999). It may
lips, and also result from
nipples. Normal male pattern chemotherapy or radiation
balding is therapy.
symmetric (Fig. 13-12). Patchy hair loss (Fig. 13-13)
may result
from infections of the scalp,
discoid or
systemic lupus
erythematosus, and some
types of chemotherapy.
Hirsutism (facial hair on
females) is a
characteristic of Cushing’s
disease and
Nails:
INSPECTION
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect nail grooming and Nails are clean and Dirty, broken, or jagged
cleanliness. manicured. fingernails may
be seen with poor hygiene.
They may
also result from the client’s
hobby or
occupation.

Inspect nail color and Pink tones should be seen. Pale or cyanotic nails may
markings Some longitudinal indicate hypoxia
ridging is normal. or anemia.
Splinter hemorrhages
may be caused by trauma.
Beau’s lines
occur after acute illness and
eventually
grow out. Yellow
discoloration may be
seen in fungal infections or
psoriasis.
Nail pitting is also common
in psoriasis
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect shape of nails. There is normally a 160- Early clubbing (180-

degree angle between degree angle with spongy
the nail base and the skin. sensation)

Late clubbing
(greater than 180-degree
angle) can occur
from hypoxia.

Spoon nails (concave)

may be present with iron
deficiency anemia
Nails:
PALPATION
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Palpate nail to assess Nails are hard and Thickened nails

texture. basically immobile. (especially toenails)
may be caused by
decreased circulation.

Palpate to assess Nails are smooth and Paronychia

texture and firm; nailplate (inflammation)
consistency, should be firmly indicates local infection.
noting whether attached to nailbed.
nailplate is attached Detachment of nailplate
to nailbed. from nailbed
(onycholysis) is seen in
infections or trauma.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test capillary refill Pink tone returns There is slow (greater

in nailbeds by immediately to than 2 seconds)
pressing the nail tip blanched nailbeds capillary nailbed refill
briefly and watching when pressure is (return of pink
for color change released. tone) with respiratory
or cardiovascular
diseases that cause
hypoxia.
Identification of
Pressure Ulcer
Stage
Primary Skin
Lesions
Type/ Description Examples

Macule, Patch • Freckles

• Flat moles
• Flat, non-palpable skin color • Petechiae
change (skin color may be • Rubella
brown, white, tan, purple, red) • Vitiligo
• Macule: 1 cm, circumscribed • Port wine stains
border • Ecchymosis
• Patch: 1 cm, may have
irregular border
Type/ Description Examples

Papule. Plaque • Elevated nevi

Papules:
• Elevated, palpable, solid • Warts
mass; circumscribed border • Lichen planus
• Papule: 0.5 cm
• Plaque: 0.5 cm (may be Plaques:
coalesced papules with flat • Psoriasis
top) • Actinic keratosis
Type/ Description Examples

Nodule, Tumor Nodules:

• Lipoma
• Elevated, solid, palpable mass
• Squamous cell carcinoma
• Extends deeper into dermis than
• Poorly absorbed injection
a papule
• Dermatofibroma
• Nodule: 0.5–2 cm;
circumscribed
Tumors:
• Tumor: 1–2 cm; does not
• Larger lipoma
always have sharp Borders
• Carcinoma
Type/ Description Examples

Vesicle, Bulla Vesicles:

• Circumscribed • Herpes simplex/zoster
elevated, palpable • Varicella (chickenpox)
mass containing • Poison ivy
serous fluid • Second-degree burn
• Vesicle: < 0.5 cm
• Bulla: > 0.5 cm Bulla:
• Pemphigus, contact dermatitis,
large
burn blisters, poison ivy, bullous
Impetigo
Type/ Description Examples
Wheal • Urticaria (hives)
• Insect bites
• Elevated mass with transient
borders
• Often irregular
• Size and color vary
• Caused by movement of serous
fluid into the dermis
• Does not contain free fluid in a
cavity (e.g., vesicle)
Type/ Description Examples

Pustule • Acne
• Impetigo
• Pus-filled vesicle or bulla • Furuncles
• Carbuncles
Type/ Description Examples

Cyst • Sebaceous cyst

• Epidermoid cyst
• Encapsulated fluid-filled or
semisolid mass
• Located in the subcutaneous tissue
or dermis
Secondary Skin
Lesions
Type/ Description Examples

Erosion • Rupture vesicles

• Scratch marks
• Loss of superficial epidermis • Aphthous ulcer
• Does not extend to the dermis
• Depressed, moist area
Type/ Description Examples

Ulcer • Stasis ulcer of

venous insufficiency
• Skin loss extending past • Pressure ulcer
epidermis
• Necrotic tissue loss
• Bleeding and scarring
possible
Type/ Description Examples

Scar (Cicatrix) • Healed wound

• Healed surgical
• Skin mark left after incision
healing of wound or lesion
• Represents replacement
by connective tissue of
the injured tissue
• Young scars: red or purple
• Mature scars: white
or glistening
Type/ Description Examples

Fissure
• Chapped lips or
hands
• Linear crack in the skin • Athlete’s foot
• May extend to the dermis
 Vascular Skin
Lesions
Vascular skin lesions are associated with bleeding,
aging, circulatory conditions, diabetes, pregnancy and
hepatic disease among other problems.
Type/ Description

Petechia (Pl. Petechiae)

• Round red or purple macule
• Small: 1–2 mm
• Secondary to blood extravasation
• Associated with bleeding tendencies
or emboli to skin
Type/ Description

Ecchymosis (Pl.
Ecchymoses)
• Round or irregular macular lesion
• Larger than petechia
• Color varies and changes: black,
yellow, and green hues
• Secondary to blood extravasation
• Associated with trauma, bleeding
tendencies
Type/ Description

Hematoma
• A localized collection of blood
creating an elevated ecchymosis
• Associated with trauma
Type/ Description

Cherry Angioma
• Papular and round
• Red or purple
• Noted on trunk, extremities
• May blanch with pressure
• Normal age-related skin alteration
• Usually not clinically significant
Type/ Description

Spider Angioma
• Red, arteriole lesion
• Central body with radiating branches
• Noted on face, neck, arms, trunk
• Rare below waist
• May blanch with pressure
• Associated with liver disease,
pregnancy, and vitamin B deficiency
Type/ Description

Telangiectasis (Venous Star)

• Shape varies: spiderlike or linear
• Color bluish or red
• Does not blanch when pressure is applied
• Noted on legs, anterior chest
• Secondary to superficial dilation of venous vessels
and capillaries
• Associated with increased venous
pressure states (varicosities)
Skin Cancer (Malignant Melanoma)
Configurations of
Skin Lesions
Common Nail
disorders
Validating and
Documenting
Findings
Analysis of Data
 1 2
After collecting subjective and Then cluster the data to reveal any
objective data pertaining to the significant patterns or
skin, hair, and nails, identify abnormalities
abnormal findings and client
strengths.

DIAGNOSTIC REASONING:
POSSIBLE CONCLUSIONS
  Readiness for enhanced skin,
Sample hair, and nail integrity
Nsg Dx: related to healthy hygiene
WELLNE and skin care practices,
avoidance of overexposure
SS to sun
01 02 03 04 05
Risk for Risk for Risk for Risk for Risk for
Impaired Impaired Skin Imbalanced Impaired Imbalanced
Skin Integrity Integrity Body Tissue Integrity Body
related to Temperature of toes related Temperature
related to prolonged sun related to to thickened, related to
excessive exposure immobility, dried toenails severe
exposure to decreased diaphoresis
cleaning production of
solutions and natural oils,
chemicals and thinning
skin

Sample Nsg Dx: RISK

 1 2 3
Ineffective Health Impaired Skin Integrity Impaired Skin Integrity
Maintenance related to related to immobility related to poor
lack of hygienic care of and decreased nutritional intake and
the skin, hair, and nails circulation bowel/bladder
incontinence

Sample Nsg Dx: ACTUAL