Skin, hair, and nail assessment
surface
Integumentary System
 Skin and accessory structures
 Hair
 Nails
Skin
 Largest Organ of the Body
 Protection from environment
 Temperature regulation
 Synthesis of vitamin D
 Storage of fat and blood
 Excretion of waste
 Sensation
 Composed of the Epidermal and Dermal Layers
The Major Functions of the Skin
 Perceiving touch, pressure, temperature, and
pain via the nerve endings
 Protecting against mechanical, chemical,
thermal, and solar damage
 Protecting against loss of water and electrolytes
 Regulating body temperature
 Repairing surface wounds through cellular
replacement
 Synthesizing vitamin D
 Allowing identification through uniqueness of
facial contours, skin and hair color, and
fingerprints
Oil or Sebaceous Glands
 Produce Sebum That Is Usually Released in Hair
Follicles
The Major Functions of the Cutaneous Glands
 Excreting uric acid, urea, ammonia, sodium,
potassium, and other metabolic wastes
 Regulating temperature through evaporation of
perspiration on the skin surface
 Protecting against bacterial growth on the skin
 Softening, lubricating, and waterproofing skin
and hair
 Resisting water loss from the skin surface in
low-humidity environments
 Protecting deeper skin regions from bacteria on
the skin surface
Hair
 Thin Fiber Compound of Dead Keratinized Cells
 Vellus
 Terminal
Nails
 Thin Plates of Keratinized Epidermal Cells That
Cover the Distal Ends of Fingers and Toes
Specific Questions
 Illness or infection
 Symptoms
 Pain
 Behaviors
 Infants and children
 Pregnant females
 Older adults
 Environment
Box I 1.2 Self-Examination of the Skin
1. Use a room that is well lit and has a full-length minor.
Have a handheld mirror and chair available. Remove all
of your clothes.
2. Examine all of your skin surface. front and back. Begin
with your hands. including the spaces between your
fingers. Continue with your arms. chest. abdomen.
pubic area. thighs, lower legs. and toes. Next examine
your face and neck. Make sure you inspect your under
arms. die sides of your trunk. the back of your neck the
buttocks. and the soles of your feet.
3. Next sit down with one leg elevated. Use the
handheld mirror to examine the inside of the elevated
leg, from the groin area to the foot. Repeat on the other LABORATORY TESTS—SKIN
leg.
Eosinophils Normal Value 1-4%
4. Use the handheld mirror to inspect your scalp.
IgE Normal Value 0.002-0.2 mg/di
5. Consult your physician promptly if you see any newly
DIAGNOSTIC TESTS—SKIN
pigmented area or if any existing mole has changed in
color, me. shape. or elevation. Also report sores that do Gram stain and culture Skin biopsy
not heal: redness or swelling around a growth or lesion;
a change in sensation such as itching. pain. tenderness. Immunostaining Skin scraping
or numbness in a lesson or the skin around it: and a Patch tests Tzanck Test
change in the tenure or consistency of the skin.
DIAGNOSTIC TESTS—
Removal of:
HAIR Trichogram—alopecia
 Clothing
DIAGNOSTIC TESTS NAILS
 Jewelry
Biopsy
 Cosmetics
Figure 11.29 Spoon nail.
 Wigs

 Hairpieces

Abnormal Skin Findings

 Primary and secondary lesions

 Vascular lesions Figure 11.30 Hemangioma.

 Purpuric lesions

 Infections

 Malignant lesions

 ABCDE Criteria

A = Asymmetry

B = Border Irregularity

C = Color Variegation

D = Diameter greater than 6 mm Figure 11.31 Port-wine stain (nevus flammeus).

E = Evolving Changes*

*Evolving changes include changes in size, shape,

symptoms (itching, tenderness), surface (bleeding) and
shades of color.

Table 11.2 Potential Secondary Sources for Client

Data Related to the Skin, Hair, and Nails
Figure 11.32 Spider (star) angioma. Figure 11.36 Ecchymosis (bruise).

Figure 11.33 Venous lake.

Figure 11.37 Hematoma.

Figure 11.34 Petechiae.

Figure 11.38 Macule and patch.

Figure 11.35 Purpura.

Figure 11.39 Papule and plaque.

Figure 11.40 Nodule and tumor.

 Figure 11.45 Atrophy.

Figure 11.41 Vesicle and bulla.

Figure 11.46 Erosion.

Figure 11.42 Wheal.

Figure 11.47 Lichenification.

Figure 11.43 Pustule.

Figure 11.48 Scales.

Figure 11.44 Cyst.

 Skin Lesions
Figure 11.49 Crust.
 Tinea

 Measles

 Varicella

 Herpes

 Psoriasis

 Dermatitis

Figure 11.50 Ulcer.  Eczema

 Impetigo

Figure 11.63 Tinea corporis.

Figure 11.51 Fissure.

Figure 11.64 Measles (rubeola).

Figure 11.52 Scar.

Figure 11.65 German measles (rubella).
Figure 11.66 Chickenpox (varicella). Figure 11.69 Psoriasis.

Figure 11.70 Contact dermatitis.

Figure 11.67 Herpes simplex.

Figure 11.68 Herpes zoster (shingles).

Figure 11.71 Eczema (atopic dermatitis).
Figure 11.72 Impetigo.

Figure 11.76 Kaposi’s sarcoma.

Malignant Lesions

 Basal cell carcinoma

 Squamous cell carcinoma

 Malignant melanoma

 Kaposi’s sarcoma

Figure 11.73 Basal cell carcinoma.

Abnormal Hair Findings

 Seborrhea

 Tinea capitis

 Alopecia areata

 Infection

 Folliculitis

Figure 11.74 Squamous cell carcinoma.  Furuncles

 Hirsutism

Figure 11.77 Seborrheic dermatitis (cradle

cap).

Figure 11.75 Malignant melanoma.

Figure 11.78 Tinea capitis (scalp ringworm).

Figure 11.79 Alopecia areata.
Abnormal Nail Findings

 Spoon nails

 Paronychia

 Beau’s line

 Splinter hemorrhage

 Onycholysis

Figure 11.83 Spoon nails (Koilonychia).

Figure 11.80 Folliculitis.

Figure 11.81 Furuncle/abscess. Figure 11.84 Paronychia.

Figure 11.82 Hirsutism. Figure 11.85 Beau’s line.

  Temperature regulation is inefficient in
infants.

Figure 11.3 Milia.

Figure 11.86 Splinter hemorrhages.

Figure 11.4 Mongolian spots.

Figure 11.88 Onycholysis.

Developmental Considerations
Special Considerations
 Pregnant Female
 Developmental, Psychosocial, Cultural, and
Environmental  Skin pigmentation increases.

Developmental Considerations  Development of melasma and the linea

nigra are common
 Pediatric
Figure 11.6 Melasma.
 Newborn skin is covered with vernix
caseosa.

 Infants have skin that is thin, soft, and

free of terminal hair.

 Milia and “Stork bites” are common,

harmless markings in newborns

 Infants may be born with lanugo

present
Figure 11.7 Linea nigra.
Developmental Considerations
 Geriatric
 Skin elasticity decreases with aging
 Sebum production decreases and
causes dryness
 Perspiration decreases
 Decrease in melanin production
resulting in graying hair
 Increased sensitivity to sunlight
 Nails tend to become thicker and more
brittle
Figure 11.8 Tenting. A. Step 1: Nurse grasps the skin.
Figure 11.8 (continued) Tenting. B. Step 2: Nurse
releases grasp, tenting present.
Psychosocial Considerations
 Stress-induced illnesses
 Visible skin disorders and self-esteem/body
image
Cultural and Environmental Considerations
 Religion
 Birth anomalies
 Dietary deficiencies
Color Variations in Light and Dark Skin
Pallor
Loss of color in skin due to the absence of oxygenated
hemoglobin. Widespread, but most apparent in face,
mouth, conjunctivae, and nails.
POSSIBLE CAUSES
 May be caused by sympathetic nervous
stimulation resulting in peripheral
vasoconstriction due to smoking, a cold
environment, or stress. May also be caused
by decreased tissue perfusion due to
cardiopulmonary disease, shock and
hypotension, lack of oxygen, or prolonged
elevation of a body part. May also be caused
by anemia
APPEARANCE IN LIGHT SKIN
 White skin loses its rosy tones. Skin with
natural yellow tones appears more yellow;
may be mistaken for mild jaundice.
APPEARANCE IN DARK SKIN
 Black skin loses its red undertones and
appears ash-gray. Brown skin becomes
yellow-tinged. Skin looks dull.
Absence of Color
Congenital or acquired loss of melanin pigment.
Congenital loss is typically generalized, and acquired
loss is typically patchy
POSSIBLE CAUSES
 Generalized depigmentation may be caused
by albinism. Localized depigmentation may
be due to vitiligo or tinea versicolor, a
common fungal infection.
APPEARANCE IN LIGHT SKIN
 Albinism appears as white skin, white or
pale blond hair, and pink irises. Vitiligo
appears as patchy milk-white areas,
especially around the mouth. Tinea
versicolor appears as patchy areas paler than
the surrounding skin.
APPEARANCE IN DARK SKIN
 Albinism appears as white skin, white or
pale blond hair, and pink irises. Vitiligo is
very noticeable as patchy milk-white areas.
Tinea versicolor appears as patchy areas
paler than the surrounding skin.
Cyanosis
Mottled blue color in skin due to inadequate tissue
perfusion with oxygenated blood. Most apparent in the
nails, lips, oral mucosa, and tongue.
POSSIBLE CAUSES
 Systemic or central cyanosis is due to
cardiac disease, pulmonary disease, heart
malformations, and low hemoglobin levels.
Localized or peripheral cyanosis is due to
vasoconstriction, exposure to cold, and
emotional stress.
APPEARANCE IN LIGHT SKIN
 The skin, lips, and mucous membranes look
blue-tinged. The conjunctive and nail beds
are blue.
APPEARANCE IN DARK SKIN
 The skin may appear a shade darker.
Cyanosis may be undetectable except for the
lips, tongue, and oral mucous membranes,
nail beds, and conjunctivae, which appear
pale or blue-tinged.
Reddish Blue Tone
Ruddy tone due to an increased hemoglobin and stasis
of blood in capillaries. Most apparent in the face,
mouth, hands, feet, and conjunctivae.
POSSIBLE CAUSES
 Polycythemia vera, an overproduction of red
blood cells, granulocytes, and platelets.
APPEARANCE IN LIGHT SKIN
 Reddish purple hue.
APPEARANCE IN DARK SKIN
 Difficult to detect. The normal skin color
may appear darker in some clients. Check
lips for redness.
Erythema
Redness of the skin due to increased visibility of normal
oxyhemoglobin. Generalized, or on face and upper
chest, or localized to area of inflammation or exposure.
POSSIBLE CAUSE
 Hyperemia, a dilatation and congestion of
blood in superficial arteries. Due to fever,
warm environment, local inflammation,
allergy, emotions (blushing or
embarrassment), exposure to extreme cold,
consumption of alcohol, dependent position
of body extremity.
APPEARANCE IN LIGHT SKIN
 Readily identifiable over entire body or in
localized areas. Local inflammation and
redness are accompanied by higher
temperature at the site.
APPEARNCE IN DARK SKIN
 Generalized redness may be difficult to
detect. Localized areas of inflammation
appear purple or darker than surrounding
skin. May be accompanied by higher
temperature, hardness, swelling.
Jaundice
Yellow undertone due to increased bilirubin in the
blood. Generalized, but most apparent in the
conjunctivae and mucous membranes
POSSIBLE CAUSE
 Increased bilirubin may be due to liver
disease, biliary obstruction, or hemolytic
 disease following infections, severe burns,
or resulting from sickle cell anemia or
pernicious anemia.
APPEARANCE IN LIGHT SKIN
 Generalized. Also visible in sclerae, oral
mucosa, hard palate, fingernails, palms of
hands, and soles of the feet.
APPEARNCE IN DARK SKIN
 Visible in the sclerae, oral mucosa, junction
of hard and soft palate, palms of the hands,
and soles of the feet.
Carotenemia
Yellow-orange tinge caused by increased levels of
carotene in the blood and skin. Most apparent in face,
palms of the hands, and soles of the feet
POSSIBLE CAUSE
 Excess carotene due to ingestion of foods
high in carotene such as carrots, egg yolks,
sweet potatoes, milk, and fats. Also may be
seen in clients with anorexia nervosa or
endocrine disorders such as diabetes
mellitus, myxedema, and hypopituitarism
APPEARANCE IN LIGHT SKIN
 Yellow-orange seen in forehead, palms,
soles. No yellowing of sclerae or mucous
membranes.
APPEARNCE IN DARK SKIN
 Yellow-orange tinge most visible in palms
of the hands and soles of the feet. No
yellowing of sclerae or mucous membranes
Uremia
Pale yellow tone due to retention of urinary
chromogens in the blood. Generalized, if perceptible.
POSSIBLE CAUSE
 Chronic renal disease, in which blood levels
of nitrogenous wastes increase. Increased
melanin may also contribute, and anemia is
usually present as well.
APPEARANCE IN LIGHT SKIN
 Generalized pallor and yellow tinge, but
does not affect conjunctivae or mucous
membranes. Skin may show bruising.
APPEARNCE IN DARK SKIN
 Very difficult to discern because the yellow
tinge is very pale and does not affect
conjunctivae or mucous membranes. Rely
on laboratory and other data.
Brown
An increase in the production and deposition of
melanin. Generalized or localized.
POSSIBLE CAUSE
 May be due to Addison’s disease or a
pituitary tumor. Localized increase in facial
pigmentation may be caused by hormonal
changes during pregnancy or the use of birth
control pills. More commonly due to
exposure to ultraviolet radiation from the
sun or from tanning booths.
APPEARANCE IN LIGHT SKIN
 With endocrine disorders, general bronzed
skin. Hyperpigmentation in nipples, palmar
creases, genitals, and pressure points. Sun
exposure causes red tinge in pale skin, and
olive-toned skin tans with little or no
reddening
APPEARNCE IN DARK SKIN
 With endocrine disorders, general deepening
of skin tone. Hyperpigmentation in nipples,
genitals, and pressure points. Sun exposure
leads to tanning in various degrees from
brown to black.
Coining refers to rubbing the skin of the back, upper
chest, neck, and arms with a coin in symmetric patterns.
Coining results in skin bruising.
Cupping is sucking of the skin on the forehead, back,
and upper chest. Glass cups are heated until air is
removed. The heated cups are placed on the skin. Red
circular lesions arise on the skin from cupping.
Pinching, when pinching, the first and second fingers
pull upward on the skin of the neck, back, and chest,
and between the eyebrows. The pinching produces
bruises. These treatments stimulate circulation and
restore balance in children and adults with a variety of
ailments.
Obese Clients
 Skinfold
 Incontinence
  Hygiene
Objectives for Skin Health Outlined in Healthy People
2020
 Occupational skin disorders
 Education on skin cancer risks and prevention
Key Objectives for Occupational Skin Disorders
 Reduce occupational skin disorders in full-time
workers
Key Objective for Skin Cancer
 Increase the number of persons using
protective measures to reduce the rate of
sunburns
Nose, Mouth, and Throat
Nose
• First segment of the respiratory
system
• Warms, moistens and filters inhaled
air
• Sensory organ for smell
• Nose warms, moistens, filters the
inhaled air and the sensory organ for
smell
External parts
• Bridge
• Tip
• Nares
• Vestibule -nares widen in to vestibule
• Columella divides the nares
• Ala —lateral outside wing of the nose bilaterally
• Upper 1/3 nose is bone; rest is cartilage
Internal
• Nasal cavity, extends back over the roof of the
mouth
• Nasal hair, ciliated mucous membrane red due to up
supply
• Septum-divides cavity into 2 passages
How WELL DO YOU KNOW YOUR NOSE?
 Inside the nares are hairs that fitter out the
coarsest matter from inhaled air. Further up
the nose is a mucous blanket which filters
out dust and bacteria.
 Within the nasal cavity we have the frontal,
maxillary. ethmoid and sphenoid sinuses.
The frontal sinuses are absent at birth and
are fairy well developed between 7-8 yrs.
old.
Principal Nasal Symptoms
• airway obstruction
• runny nose (rhinorrhoea)
• sneezing
• loss of smell (anosmia)
• facial pain due to sinusitis
• snoring associated with nasal obstruction
Nasal Turbinates
 Turbinates, which are also called nasal concha
or conchae (plural), are shell-shaped networks
of bones, vessels, and tissue within the nasal
passageways.
 These structures are responsible for warming,
humidifying, and filtering the air we breathe.
 Normally there are three turbinates including
the superior (upper), middle, and inferior
(lower) turbinates. However, occasionally you
can have a fourth turbinate (called the supreme
turbinate) which is situated higher than the
superior turbinate. 
NORMAL FINDINGS OF THE NOSE
The nose should be symmetrical, in the midline, and in
proportion to other facial features. Inspect for any
deformity, asymmetry, inflammation or skin lesions.
PROPER ASSESSMENT TECHNIQUES
Always wear a mask and gloves. Lean the patient back
as far as you can. Use your pin light, Otoscope, tongue
depressor, and mouth mirror. Tell the patient what you
are doing and why.
ASSESSMENT
Inspection Condensation should be visible as air passes over the
metal.
Using the Otoscope, note any swelling, discharge,
bleeding, or foreign bodies. To assess nasal airway efficiency. Occlude one nostril
and ask the patient to sniff. This gives a reasonable idea
Palpation
on nasal airway efficiency.
Checking the sinuses, pt should feel firm pressure but
What is considered an abnormality?
no pain.
• Pain
Inspection
• Trauma
• Nose
• Sores or lesions
• Shape - Deviation. Look from the sides & from
above. • Epistaxis (nose bleeds)

• Deformities - Abnormal Nasal Creases • Allergies

• Scars • Hoarseness

• Discharge or crusting • Bleeding gums

• Redness or evidence of skin disease • Dysphagia

• Offensive odour (From the Patient) • Xerostomia (dry mouth)

• Rhinorrhoea • Altered taste

Inspect the front of the nose first by tipping the nose up
and inspecting without a speculum.
Insert a Thudicum speculum into the appropriate
nostril. A light source is required to visualise the internal
structures.
You should be able to identify the septum medially, the
turbinates laterally. The inferior turbinates should be
easy to visualise.
Inspect for inflammation (Rhinitis)
Comment on the septum. Is it straight or deviated.
Look in the mouth. Occasionally large polyps or tumours
may be visible from arising behind the soft palate.
Palpation
• Discharge
• Sore throat
• Toothache
WHAT YOU COULD SEE IN THE NOSE
 You might see a screw up a 2yr olds nose.
Perforated Septum - A hole in the septum, usually in the
cartilaginous part, may be caused by snorting cocaine,
chronic infection, trauma from continual picking of
crusts, or nasal surgery.
Allergic Rhinitis - Rhinorrhea, itching of nose and eyes,
nasal congestion, and sneezing. Note the serous edema
and swelling to fill the air space.

If you see what you believe is a polyp then it is useful to
assess sensitivity. Polyps are not sensitive to touch
whereas turbinates are tender to touch.
Polyps are grey / yellow whereas turbinates are pink.
Nasal Airway Assessment
A healthy nose, mouth, and throat are all disease free
with no lumps, bumps, swellings, decay, discharge or
color disturbances. They need to be pink and healthy
looking. Now you knew I would put a picture on here of
dental floss!

Hold a cold metal tongue depressor under the patient’s

nose whilst they breath in and out through their nose.
HAVE A LOOK INSIDE YOUR MOUTH!
1 Palatine raphé
2 Hard palate
3 Vibrating line (at junction of hard/soft palates)  4 Soft
palate
5 Uvula
6 Maxillary tuberosity
7 Posterior pilar (pharyngopalatine muscle)
8 Anterior pillar (glossopalatine muscle)
9 Posterior wall of pharynx
10 Palatine tonsil
11 Retromolar area
12 Deep lingual artery/vein
13 Fimbriated fold
14 Frenulum of tongue
15 Sublingual fold
16 Sublingual caruncle (with opening of submandibular
duct)
THE TONGUE IS MADE UP OF SEVEN (7) DIFFERENT
KINDS OF MUSCLES FOR MASTICATION, SWALLOWING,
CLEANSING OF THE TEETH AND SPEECH. THE SALIVARY
GLANDS ARE TO MOISTEN AND LUBRICATE THE FOOD
BOLUS, START DIGESTION, AND CLEAN AND PROTECT
THE MUCOSA. WE HAVE 32 TEETH AND THEY WANT TO
BE SEEN BY YOUR DENTIST AND FRIENDLY LOCAL
REGISTERED DENTAL HYGIENIST!!
NORMAL FINDINGS IN THE MOUTH
As a dental hygienist I look for coral or pink coloring
with stippling in the gum tissue and good alignment of
the teeth. I want to see an absence of decay, recession,
infection, broken teeth, periodontal disease, or
gingivitis.
ABNORMALITIES OF THE MOUTH EXCESS BONE
FORMATION
Palatal Tori is in the roof of the mouth
Tori is located in the bottom of the mouth
Black Hairy Tongue: from over use of antibiotics,
hydrogen peroxide or smoking.
Cleft lip and palate: the malformation of the palate.
Mucocele: is a pocket of mucus that forms when a
minor salivary glands are occlude.
PERIODONTAL DISEASE
This is a mouth full of infection, tarter, and recession.
Yes, I see cases like this. PERIODONTAL DISEASE Dental
hygienists probe and take measurements to assess the
health of the gum tissue. A hygienist should probe no
further than 3mm. This picture notes about an 7 mm
pocket under the gum line.
Baby Bottle Decay is shown below. It occurs in infants
and toddlers who take a bottle of milk, juice, or
sweetened drink to bed and prolong bottle-feeding past
the age of one year. The white lesions are the start of
decay.
Tooth decay: it takes 3-5 years to develop. It can be
prevented! BRUSH AND FLOSS!!
Gingival Hyperplasia: mainly associated with Dilantin.
Kaposi Sarcoma in an AIDS patient
Syphilis at the site of inoculation
Leukoplakia: chalky white, thick, raised patch with will-
defined borders. Will not wipe off. Dental professionals
usually monitor it.
Darker pigmentation on the gum tissue is seen in
Caucasians who has ethnicity in their heritage.
Notice the severe wearing of the upper teeth. This is
due to bruxism (grinding).
This person has an open bite because of a tongue
thrust. Also mal occlusion is noted due to the bilateral
cross bite.
THROAT
THE THROAT CONSIST OF THE OROPHARYNX, TONSILS,
AND THE NASOPHARYNX. TONSILS ARE A MASS OF
LYMPHOID TISSUE WHICH AIDE IN THE IMMUNE
RESPONSE. OCCASIONALLY, TONSILS CAN DEVELOP
DEEP CRYPTS IN WHICH FOOD PARTICLES CAN GET
CAUGHT.
Throat Examination History.
Enquire on general history.

 Sore throat, feeling run down, visible lesions

& causing pain.
Ask about alcohol & tobacco habits.

Ask about their general dental history.

NORMAL FINDINGS OF THE THROAT

A healthy throat should be pink with no lumps, bumps

or color disturbances. Say “AHHHH”!

ABNORMATLIES OF THE THROAT

Acute Tonsillitis and Pharyngitis: bright red throat;

swollen tonsils, white or yellow exudate on tonsils and
pharynx, with swollen uvula.

Bifid Uvula: May indicate a submucous cleft plate.

Many may have the uvula removed due to snoring.

Parotid

The parotid salivary gland is located over the

mandibular ramus, anteriorly and inferiorly to the ears.

Inspection of stensen’s duct may require inspection if

the mouth is dry or if any parotid swelling is detected
upon external palpation.

Parotid Palpation

Palpated bilaterally

Start palpating anterior to the ears and move towards

the cheek and then inferiorly towards the angle of the
mandible.