SKIN

NAIL PHYSICAL
S ASSESSMEN
T
HAIR
HEAD
 SKIN

Epidermis
■ Outer layer
■ M a d e o f squa m o us e p ithelia l tissue

Dermis
■ Thick, deeper layer
■Consists of connective tissue a n d a n extracellular
material (matrix), which contributes to the skin’s
strength a n d pliability
■ Location of blood vessels, lymphatic vessels,
nerves,
h a ir follic les, a nd swe a t a nd seba c e o us gla nds
Subcutaneous tissue
■ Beneath dermis a n d epidermis
■ Consists mostly of adipose a n d other connective
tissues
FUNCTIONS OF SKIN
PROTECTION SENSATION

HEAT ABSORPTION
REGULATION

SECRETION EXCRETION
 ASSESSMENT FINDINGS
INSPECTION NORMAL
ABNORMAL Evenly c o lo red Jaundice
skin tones
without Pallo
unusual or r
prominent Acanthosis nigricans
discolorations
GENERA
C y anosi
L
SKIN COLOR s
Older client
looks pale d u e
to decrease
melanin
production
a n d vascularity
 ASSESSMENT FINDINGS
INSPECTION NORMAL ABNORMAL
Sun-tanned areas Albinism
COLOR VARIATIONS Freckles Erythema
Vitiligo

Skin is intact and Pressure ulcers

SKIN INTEGRITY there are no
reddened areas

Smooth, without Primary lesions

lesions Secondary lesions
Stretch marks
Healed
LESIONS
scars Moles
Freckels
Birthmarks
 PRIMARY LESIONS
PAPULE
MACULE Elavated, solid
Skin color lesion of less
c h a nge than 1cm
without varying in color
elevation

PATCH PLAQUE
Skin color Raised flat lesion
c h a n g e greater formed from
than 1cm m e rging
p a p ule s or
nodules
 PRIMARY LESIONS

NODULE VESICLE
Elevated, a small fluid-
p a lp a b le , fille d b la d d e r,
solid mass, sac
0.5-2cm

BULLA
TUMOR is a fluid-fille d sac
Extend deeper or lesion that
into dermis, appears when
1-2 c m fluid is trapped
under a thin layer
of your skin
 PRIMARY LESIONS
CYST
WHEAL
Encapsulated
a n area of the
fluid filled or
skin which is
semi solid mass
temporarily
raised, typically
Located in the
reddened,
subcutaneous
a n d usually
tissue or
accompanied
dermis
by itching.

PUSTULE
Pus filled vesicles
 SECONDARY LESIONS

EROSION ULCER
Loss of superficial epidermis Skin loss extending dermis

Does not extend to the dermis Necrotic tissue loss

Depressed, moist area Bleeding a n d scarring possible

 SECONDARY LESIONS

SCAR FISSURE
Skin mark left after wound heal Linear crack in the skin

Represent replacement by connective M a y extend to the dermis

tissue of the injured tissue
 VASCULAR
LESIONS
Ecchymosis Cherry Angioma Spider Angioma

Capillary hemangioma

Telangiectasis

Petechia

Port -wine stain

 SKIN ECZEMA/
ABNORMALITIES
ACNE VULGARIS ACTINIC KERATOSIS
ATOMIC
DERMATITIS
Ca u s e d by over- Causes reddish,
Causes redness, pruritus,
activity of sebaceous irregular, slightly raised
itchy, c a n cause skin
gland a n d a n onset of lesions that have a
irritation a n d it has red
puberty rough, gritty surface
to red-brown, slightly
scaly lesions
SKIN
ABNORMALITIES Localized skin
irritation,
inflammation, a n d
pruritus from
co ntact with a n
irritating substance

A contagious
disease caused by A c o m m o n dermatitis that
the herpes has genetic causes a n d
may begin at any age,
simplex virus. Silvery scales on bright red
Recurrent clusters papules, Scales generally
of small vesicles thick, Area beneath bleeds
on erythematous if scale is removed
base
 ASSESSMENT FINDINGS

PALPATION NORMAL ABNORMAL

Smooth a n d Rough, flaky,

TEXTURE
even dry, itchy
Diaphoresis
MOISTURE Moist a n d dry Decrease
moisture
C o l d skin
TEMPERATURE Warm Very warm
skin
 ASSESSMENT FINDINGS
PALPATION NORMAL ABNORMAL

Skin pinches Decrease

easily a n d mobility is seen
MOBILITY
immediately with e d e m a
AND
returns to its
TURGOR
original Client
position dehydrated
Skin rebounds
a n d does
EDEMA not remain With indention
indented
when pressure
is released
 PHYSICAL ASSESSMENT OF THE
🠶 Greet aSKIN
n d identify the client 🠶 Inspect, palpate a n d describe skin
🠶 Explain the procedure
🠶 Wash hands
🠶 Provide for client privacy
🠶 Position client appropriately a n d
comfortably
🠶 Inquire if the client has any history of
skin allergies a n d skin problems
🠶 Inspect for the skin color a n d
uniformity of skin color
🠶 Assess e d e m a if present. Note location,
color, temperature, shape a n d degree to
which the skin remains indented or
pitted when pressed by a finger
lesions
🠶 Observe a n d palpate skin moisture
🠶 Palpate skin temperature
🠶 Note skin turgor
🠶 Position the client comfortably
🠶 Inform the client findings if
necessary
🠶 Wash hands
🠶 Document findings a n d
report significant deviation
to the physician
 QUESTIONS TO BE ASKED FROM THE
C LIENT
🠶 History of client
🠶 Have you noticed any c h a n g e in your ability to feel pain, pressure, light touch or
temperature variations?
🠶 Are you experiencing any pain, itching, tingling, or numbness
🠶 Are taking any medications(prescribed/over the counter) d o you use any ointments,
creams, herbal a n d nutritional supplements or vitamins? How long have you b e en
taking e a c h of these?
🠶 Do you have any trouble controlling b od y odor? Do you perspire a lot?
🠶 Have you h a d any recent hospitalizations or surgeries
🠶 Have you ever h a d any allergic reactions to food medications, plants or
other environmental substances?
🠶 Has anyone in your family h a d a recent illness, rash, or other skin problem or
allegy?
🠶 Has anyone in your family h a d skin c a n c e r ?
🠶 Do you have any history of keloids?
HAIR - is formed from keratin p roduced by
matrix cells in the dermal layer of the skin. Each
hair lies in a hair follicle.
FUNCTION OF HAIR

PROTECTION

REGULATION OF BODY TEMPERATURE

FACILITATION OF EVAPORATION
OF PERSPIRATION

SENSE ORGAN
 ASSESSMENT FINDINGS
INSPECTION NORMAL ABNORMAL
Natural hair
COLOR Patchy gray hair
color
Excessive scaliness
MOISTURE Shiny
Poor hygiene
Presence of
dandruff a n d
SCALP Clean
parasites
Al o p eci a
Thick a n d Brittle hair
TEXTURE fine Split ends
Dry
 NA IL - are formed when epidermal cells
are converted into hard plates of keratin.
The cuticle, a layer of keratin at the nail fold,
attaches the nail plate to the soft tissue of the nail
fold.

The nail body is translucent, and the pinkish

hue reflects a rich blood supply beneath the nail
surface

Lunula is nail plate which is slightly hypopigmented than

nail. The lunula contains stem cells and nail plate matrix
which helps the growth of the nail. If it gets damaged
your nail cant grow well.
 ASSESSMENT FINDINGS

INSPECTION NORMAL ABNORMAL

Colorless a n d
NAILS Concave
a convex
curve
Clubbed fingernails
Angle between
(>180°) d u e to
nail a n d nail
chronic tissue
b e d usually
hypoxia
160°
Highly vascular
a n d pink in Bluish or
light skinned; purplish tinges;
dark skinned Pale
m ay b e brown
 ASSESSMENT FINDINGS
Perform blanch test/ Capillary
refill test -is a q uic k test d o n e
o n the nail b eds. It is use d to
monitor dehydration a n d the
amount of blood flow to tissue.
N ormal 1 – 2secs

ABNORMAL FINDINGS:
A CRT longer than 2 seconds
suggests poor perfusion due
to peripheral
vasoconstriction.
SCAMROTH SIGN/SCHAMROTH
WINDOW
 COMMON NAIL
DISORDERS
Koilonychia Spoon-shaped nails that
may b e seen with trauma to cuticles
or nail folds or in iron deficiency
anemia, endocrine or c a rd i a c
disease).

Yellow Nail Syndrome Yellow nails

grow slow a n d are curved. M a y b e
seen in AIDS a n d respiratory
syndromes.

Paronychia Local infection.

 COMMON NAIL
DISORDERS
Longitudinal ridging parallel ridges
running lengthwise. M a y b e seen in
the elderly a n d some young
p eo p le with no known etiology.

Half-and-Half Nails nails that are

half white on the upper proximal
half a n d pink on the distal half. M a y
b e seen in chronic renal disease.

Pitting Seen with pso riasis

 A S SESSMENT FINDINGS OF THE HEA D

INSPECTION NORMAL ABNORMAL

HEAD Symmetric, Facial
Size, Shape, Round, Erect a n d skull
Symmetry a n d in bones are
Midline larger a n d
thicker
Fa c e Symmetric, Assymetrical
Symmetry, Round, Oval, face
Features, Elongated, Mask like
Movement, Square face
Expression, a p p e a ra n c e Sunken eyes
Skin condition Moon
shaped f a c e
 A S SESSMENT FINDINGS OF THE HEA D
PALPATION NORMAL ABNORMAL

Normally hard Lesions, Lumps

HEAD
a n d smooth may indicate
Consistency
without deviation tumor or trauma

Hard, Thick,
Elastic a n d not
TEMPORAL a n d tender
tender
ARTERY with
inflammation

No swelling,
Limited ROM,
TEMPOROMANDIBULAR tenderness, a n d
swelling, tenderness,
JOINT (TMJ) crepitation
Crepitation
with
movement
NECK –
c o m posed
of
muscles
ligaments
a n d the
cervical
vertebrae
 A S SESSMENT FINDINGS OF THE NECK

INSPECTION NORMAL ABNORMAL

Neck is symmetric with
With swelling,
Position, symmetry, h e a d centered a n d
enlarged masses
lumps and masses without bulging
or nodules
masses
Thyroid cartilage,
Movement of the neck cricoid cartilage, Asymetric
structure(thyroid gland thyroid gland m ove movement or
and thyroid cartilage upward generalized
symmetrically as the enlargement
client swallows

C7 is usually visible Prominence or

Cervical vertebrae
a n d palpable swelling

Smooth a n d Stiffness, rigidity,

ROM
controlled limited mobility
 A S SESSMENT FINDINGS OF THE NECK
PALPATION NORMAL ABNORMAL
TRACHEA (position) Midline Pulled to one side

THYROID GLAND
Deviated from midline
Hyoid b on e Midline m a y b e because of
Thyroid cartilage
masses
Cricoid cartilage

No swelling,
CERVICAL Swelling, enlargement
enlargement and
LYMPH NODES a n d tenderness
tenderness

AUSCULTATE the
thyroid gland if there is No bruits are A soft, blowing,
enlargement during auscultated swishing sound
inspection a n d
palpation
Neck Lymph
Nodes
Auscultation