Assessment

of
Skin, Hair, &
Nails
HEALTH ASSESSMENT
PAU L A N D R E A . LU M I G U I D R N M A N ,
CLSSYB,PHD C.
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?

▪ 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
Preparin enamel, artificial nails, wigs,
toupees, or hairpieces as
g the appropriate.

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
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 Client has slight or A strong odor of

skin coloration, note no odor of perspiration or foul
any odors perspiration, odor may indicate
emanating from the depending on disorder of sweat
skin. activity. 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
patches known as people) or darkened
vitiligo (in dark-skinned
people) butterfly
rash across the
bridge of the nose
and cheeks

Albinism

Erythema- seen in
inflammation,
allergic reactions, or
trauma.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Check skin integrity, Skin is intact, and there Skin breakdown is

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

Inspect for Smooth, without lesions. Primary lesions arise

Stretch marks from normal skin due to
lesions. Observe (striae), healed scars, irritation or disease.
the skin freckles, moles, or
surface to detect birthmarks are common Secondary lesions arise
findings from changes in primary
abnormalities. Note lesions.
color, shape, and
size of lesion. For Vascular lesions,
reddish-bluish lesions, are
very seen
small lesions, use a with bleeding, venous
magnifying glass to pressure, aging, liver
disease, or pregnancy.
note these
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
Wood’s indicates 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).
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate skin to assess Skin is smooth and even. Rough, flaky, dry skin is
texture. Use the seen in hypothyroidism.
palmar surface of your Obese clients often report
three middle fingers dry, itchy skin.
to palpate skin texture.

Palpate to assess Skin is normally thin but Very thin skin may be seen
thickness. If lesions calluses (rough, in clients
are noted when assessing thick sections of with arterial insufficiency or
skin thickness, epidermis) are common in those on
put gloves on and palpate on areas of the body that steroid therapy.
the lesion between are exposed to
the thumb and finger. constant pressure.
Observe for
drainage or other
characteristics.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate to assess Skin surfaces vary Increased moisture or
moisture. Check from moist to dry diaphoresis (profuse
under skin folds and depending on the sweating) may occur
in unexposed areas. area assessed. in conditions such as
Recent activity or a fever or
➤ Clinical Tip • Some warm environment hyperthyroidism.
nurses believe that using may cause increased Decreased moisture
the dorsal surfaces of the moisture. occurs with
hands to assess moisture
leads to a more accurate dehydration
result. or hypothyroidism.
Palpate to assess Skin is normally a warm Cold skin may accompany
temperature. Use the temperature. shock or hypotension.
dorsal surfaces of your Cool skin may accompany
hands to palpate arterial disease. Very
warm skin may indicate
the skin a febrile state or
hyperthyroidism.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Palpate to assess Skin pinches easily and Decreased

immediately returns
mobility and to its original position. mobility is seen with
turgor. The older client’s skin edema.
Ask the client to lie down. loses
Using two fingers, its turgor because of a Decreased turgor
gently pinch the skin on decrease (a slow return of the skin
the sternum or under the in elasticity and collagen to its normal state taking
clavicle fibers. longer
Sagging or wrinkled skin than 30 seconds) is seen
Mobility refers to how appears in the in dehydration
easily the skin can be facial, breast, and scrotal
pinched. areas.

Turgor refers to the skin’s

elasticity and how quickly
the skin returns to
its original shape after
being pinched.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Palpate to detect Skin rebounds and does

not remain indented
Indentations on
edema. Use your when pressure is released.
the skin may vary from
thumbs to press down on slight to great and may be
the skin of in one area or
the feet or ankles to check all over the body
for edema
(swelling related to
accumulation of fluid
in the tissue).
Scalp and Hair
INSPECTIONS AND PALPATION
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Have the client remove Natural hair color, as Nutritional deficiencies

any hair clips, opposed to chemically may
hair pins, or wigs. Then colored hair, varies among cause patchy gray hair in
inspect the clients some clients. Severe
scalp and hair for from pale blond to black to malnutrition in
general color and gray or white. African-American children
condition. The color is determined by may cause
the amount of a copper-red hair color
melanin present. (Andrews &
Boyle, 1999).

At 1-inch intervals, Scalp is clean and dry. Excessive scaliness may

separate the hair Sparse dandruff indicate dermatitis.
from the scalp and may be visible. Hair is Raised lesions may
inspect and palpate smooth and firm, indicate infections
the hair and scalp for somewhat elastic. or tumor growth. Dull, dry
cleanliness, dryness However, as people hair
or oiliness, parasites, age, hair feels coarser and may be seen with
and lesions drier. hypothyroidism and
(Fig. 13-9). Wear gloves if Individuals of black African malnutrition. Poor hygiene
lesions are descent may indicate
suspected or if hygiene is often have very dry scalps a need for client teaching
poor. and dry, fragile hair, which or assistance
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect amount and Varying amounts of Excessive generalized hair

distribution of terminal hair cover loss may
scalp, body, axillae, and the scalp, axillary, body, occur with infection,
pubic hair. and pubic areas nutritional deficiencies,
Look for unusual growth according to normal hormonal disorders,
elsewhere on gender distribution. thyroid
the body. Fine vellus hair covers the or liver disease, drug
entire body toxicity, hepatic
except for the soles, or renal failure (Sabbagh,
palms, lips, and 1999). It may
nipples. Normal male also result from
pattern balding is chemotherapy or radiation
symmetric (Fig. 13-12). therapy.
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
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Inspect nail grooming Nails are clean and Dirty, broken, or jagged
and 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
markings Some longitudinal may 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
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Palpate nail to Nails are hard and Thickened nails

assess 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
noting whether attached to nailbed. infection.
nailplate is attached
to nailbed. Detachment of
nailplate
from nailbed
(onycholysis) is
seen in infections or
trauma.
PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Test capillary refill Pink tone returns There is slow

in nailbeds by immediately to (greater than 2
pressing the nail blanched nailbeds seconds) capillary
tip briefly and when pressure is nailbed refill (return
watching released. of pink
for color change tone) with
respiratory or
cardiovascular
diseases that cause
hypoxia.
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, • Port wine stains
circumscribed border • Ecchymosis
• Patch: 1 cm, may have
irregular border
Type/ Description Examples

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

Nodule, Tumor Nodules:

• Lipoma
• Elevated, solid, palpable
• Squamous cell carcinoma
mass
• Poorly absorbed injection
• Extends deeper into dermis
• Dermatofibroma
than a papule
• Nodule: 0.5–2 cm;
Tumors:
circumscribed
• Larger lipoma
• Tumor: 1–2 cm; does not
• Carcinoma
always have sharp Borders
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
• Urticaria (hives)
Wheal • 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
• Acne
Pustule • 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
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
• Stasis ulcer of
Ulcer venous insufficiency
• Skin loss extending past • Pressure ulcer
epidermis
• Necrotic tissue loss
• Bleeding and scarring
possible
Type/ Description Examples
• Healed wound
Scar (Cicatrix) • 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
VA S C U L A R S K I N L E S I O N S A R E A S S O C I AT E D
W I T H B L E E D I N G , AG I N G , C I RC U L AT O RY
C O N D I T I O N S , D I A B E T E S , P R E G N A N CY A N D
H E PAT I C D I S E A S E A M O N G O T H E R P R O B L E M S .
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

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

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)
Validating and
Documenting
Findings
 1 2
After collecting subjective and Then cluster the data to reveal
objective data pertaining to the any significant patterns or
skin, hair, and nails, identify abnormalities
abnormal findings and client
strengths.

DIAGNOSTIC REASONING:
POSSIBLE CONCLUSIONS
Sample
Nsg Dx: ▪ Readiness for enhanced skin, hair, and
nail integrity related to healthy hygiene
and skin care practices, avoidance of
WELLNE overexposure to sun

SS
01 02 03 04 05
Risk for Risk for Risk for Risk for Risk for
Impaired Impaired Skin Imbalanced Impaired Imbalanced
Skin Integrity Body Tissue Body
related to Temperature Integrity of Temperature
Integrity prolonged sun related to toes related to related to
related to exposure immobility, thickened, severe
excessive decreased dried toenails diaphoresis
exposure to production of
cleaning natural oils,
solutions and thinning
and skin
chemicals

Sample Nsg Dx: RISK

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

Sample Nsg Dx: ACTUAL