Assessing Skin, Hair and Nails

Structure and Function

• The integumentary system consists of the skin, hair, and nails, which are external structures that serve a variety
of specialized functions.

• The sebaceous and sweat glands originating within the skin also have many vital functions. Each structure’s
function is described separately.

COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY

• Diseases and disorders of the skin, hair, and nails may be local or caused by an underlying systemic condition.

• To perform a complete and accurate assessment, collect data about current symptoms, the client’s past and
family history, and lifestyle and health practices. The information obtained provides clues to the client’s overall
level of functioning in relation to the skin, hair, and nails.

• Ask questions in a straightforward manner. Keep in mind that a nonjudgmental and sensitive approach is
needed if the client has abnormalities that may be associated with poor hygiene or unhealthful behaviors.

• Also, some skin disorders might be highly visible and potentially damaging to the person’s body image and self-
concept.

History of Present Health Concern

Skin

• Are you experiencing any current skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising,
swelling, or changes in skin color? What aggravates the problem? What relieves it?

• Do you have any birthmarks or moles? If so, please describe them. Have any of them changed color, size, or
shape?

• Have you noticed any change in your ability to feel pain, pressure, light touch, or temperature variations?

• Are you experiencing any pain, itching, tingling, or numbness?

• Are you taking any medications (prescribed or “over the counter”), using any ointments or creams, herbal or
nutritional supplements, or vitamins? How long have you been taking each of these?

• Do you have trouble controlling body odor? How much do you perspire?
HAIR AND NAILS

• Have you had any hair loss or change in the condition of your hair? Describe.

• Have you had any change in the condition or appearance of your nails?

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?

• What is your daily routine for skin, hair, and nail care? What products do you use (e.g., soaps, lotions, oils,
cosmetics, selftanning products, razor type, hair spray, shampoo, coloring, nail enamel)? How do you cut your
nails?

• What kinds of foods do you consume in a typical day? How much fluid do you drink each day?

• For male clients: Do you have a history of smoking and/or drinking alcohol?

• Do skin problems limit any of your normal activities?

• Describe any skin disorder that prevents you from enjoying your relationships.

• How much stress do you have in your life? Describe.

HOW TO EXAMINE YOUR OWN SKIN

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

• Physical assessment of the skin, hair, and nails provides data that may reveal local or systemic problems or
alterations in a client’s self-care activities.
 • Local irritation, trauma, or disease can alter the condition of the skin, hair, or nails. Systemic problems related
to impaired circulation, endocrine imbalances, allergic reactions, or respiratory disorders may also be revealed
with alterations in the skin, hair, or nails.

• The appearance of the skin, hair, and nails also provides the nurse with data related to health maintenance and
self-care activities such as hygiene, exercise, and nutrition.

• A separate, comprehensive skin, hair, and nail examination, preferably at the beginning of a comprehensive
physical examination, ensures that you do not inadvertently omit part of the examination. As you inspect and
palpate the skin, hair, and nails, pay special attention to lesions and growths.

PREPARING THE CLIENT

• To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on
an examination gown.

• In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate.

• Have the client sit comfortably on the examination table or bed for the beginning of the examination. The client
may remain in a sitting position for most of the examination.

• However, to assess the skin on the buttocks and dorsal surfaces of the legs properly, the client may lie on her
side or abdomen.

• During the skin examination, ensure privacy by exposing only the body part being examined.

• Make sure that the room is a comfortable temperature. If available, sunlight is best for inspecting the skin.
However, a bright light that can be focused on the client works just as well.

• 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

• Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the
same sex as the client.

• Also, to respect the client’s modesty or desire for privacy, provide a long examination gown or robe.

Equipment

• Examination light • Gloves

• Penlight • Wood’s light (Optional)

• Mirror for client’s self-examination of skin • Examination gown or drape

• Magnifying glass (Optional) • Braden Scale for Predicting Pressure Sore Risk

• Centimeter ruler • Pressure Ulcer Scale for Healing (PUSH) tool to

measure pressure ulcer healing

Physical Assessment

When preparing to examine the skin, hair, and nails, remember these key points:

• Inspect skin color, temperature, moisture, texture.

• Check skin integrity.

• Be alert for skin lesions.

• Evaluate hair condition; loss or unusual growth.

 • Note nail bed condition and capillary refill.

ASSESSMENT PROCEDURE

SKIN Inspection

• Inspect general skin coloration. Keep in mind that the amount of pigment in the skin accounts for the intensity
of color as well as hue.

– Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones
vary from pale to ashen without underlying pink.

– Cyanosis may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and
conjunctival areas. Dark skin may appear blue, dull, and lifeless in the same areas. Central cyanosis
results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting
from vasoconstriction.

– Jaundice in light- and darkskinned people is characterized by yellow skin tones, from pale to pumpkin,
particularly in the sclera, oral mucosa, palms, and soles.

– Acanthosis nigricans is roughening and darkening of skin in localized areas, especially the posterior
neck. A linear streak-like pattern in dark-skinned people, suggests diabetes mellitus.

• While inspecting skin coloration, note any odors emanating from the skin.

• A strong odor of perspiration or foul odor may indicate disorder of sweat glands. Poor hygiene
practices may indicate a need for client teaching or assistance with activities of daily living.

• Inspect for color variations. Inspect localized parts of the body, noting any color variation

– Common variations include suntanned areas, freckles, or white patches known as vitiligo. A generalized
loss of pigmentation is seen in albinism.

– Abnormal findings include rashes, such as the reddish (in light-skinned people) or darkened (in dark-
skinned people) butterfly rash (also called Malar rash) across the bridge of the nose and cheeks,
 characteristic of systemic lupus erythematosus (SLE).

– Erythema (skin redness and warmth) is seen in inflammation, allergic reactions, or trauma.

Vitiligo Albanism

Malar Rash
Erythema

• Check skin integrity. Pay special attention to 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.

– In the obese client, carefully inspect skin on the limbs, under breasts, and in the groin area where
problems are frequent due to perspiration and friction.

– Skin breakdown is initially noted as a 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.

Common Ulcer Sites

• Inspect for lesions. Observe the skin surface to detect abnormalities.

– Note color, shape, and size of lesion. For very small lesions, use a magnifying glass to note these
characteristics.

– Note its location, distribution, and configuration.

– Measure the lesion with a centimeter ruler.

– 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 lesions , reddish-bluish lesions, are seen with bleeding, venous pressure, aging, liver disease, or
pregnancy.

– Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell
carcinoma, basal cell carcinoma, or malignant melanoma

– For abnormal lesions, distribution may be diffuse (scattered all over), localized to one area, or in sun-
exposed areas. Configuration may be discrete (separate and distinct), grouped (clustered), confluent
(merged), linear (in a line), annular and arciform (circular or arcing), or zosteriform (linear along a nerve
route).

• Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile
lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

Skin Palpation

• Palpate skin to assess texture. Use the palmar surface of your three middle fingers to palpate skin
texture.

• Rough, flaky, dry skin is seen in hypothyroidism. Obese clients often report dry, itchy skin.

• Palpate to assess thickness.

• Very thin skin may be seen in clients with arterial insufficiency or in those on steroid therapy

Note:

• If lesions are noted when assessing skin thickness, put gloves on and palpate the lesion
between the thumb and index finger for size, mobility, consistency, and tenderness.

• Infected lesions may be tender to palpate. Nonmobile, fixed lesions may be cancer.

• Palpate to assess moisture. Check under skin folds and in unexposed areas.
 • Increased moisture or diaphoresis (profuse sweating) may occur in conditions such as fever or
hyperthyroidism. Decreased moisture occurs with dehydration or hypothyroidism.

• Clammy skin is typical in shock or hypotension.

• The older client’s skin may feel dryer than a younger client’s skin because sebum production
decreases with age.

• 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.

– Cold skin may accompany shock or hypotension. Cool skin may accompany arterial
disease. Very warm skin may indicate a febrile state or hyperthyroidism.

• 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.

– 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.

• 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).

• Indentations on the skin may vary from slight to great and may be in one area or all over the
body. See Chapter 22, Assessing Peripheral Vascular System, for a full discussion of edema.

Scalp and Hair Inspection and Palpation

• Inspect the scalp and hair for general color and condition.

• Nutritional deficiencies may cause patchy gray hair in some clients. Severe malnutrition in
African American children may cause a copperred hair color.

• 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. 14-10). Wear gloves if lesions are
suspected or if hygiene is poor.

• Excessive scaliness may indicate dermatitis. Raised lesions may indicate infections or tumor
growth. Dull, dry hair may be seen with hypothyroidism and malnutrition.

• may indicate a need for client teaching or assistance with activities of daily living. Pustules

• Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease (ringworm)

• Infections of the hair follicle (folliculitis) appear as pustules surrounded by

 • Inspect amount and distribution of scalp, body, axillae, and pubic hair. Look for unusual growth elsewhere on
the body.

• Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal
disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure. It may also result from
chemotherapy or radiation therapy.

• Patchy hair loss 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 results from an
imbalance of adrenal hormones or it may be a side effect of steroids.

• Older clients have thinner hair because of a decrease in hair follicles. Pubic, axillary, and body
hair also decrease with aging. Alopecia is seen, especially in men. Hair loss occurs from the
periphery of the scalp and moves to the center.

Nails Inspection

• Inspect nail grooming and cleanliness.

• Dirty, broken, or jagged fingernails may be seen with poor hygiene. They may also result from
the client’s hobby or occupation.

• Inspect nail color and markings

• Pale or cyanotic nails may indicate hypoxia 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.

• Inspect shape of nails

Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur
from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia

PALPATION

• Palpate nail to assess texture.

• Thickened nails (especially toenails) may be caused by decreased circulation, and is also seen in
onychomycosis.

• Older clients’ nails may appear thickened, yellow, and brittle because of decreased circulation
in the extremities

• Palpate to assess texture and consistency, noting whether nail plate is attached to nail bed.

• Paronychia (inflammation) indicates local infection. Detachment of nail plate from nail bed
(onycholysis) is seen in infections or trauma.

• Test capillary refill in nail beds by pressing the nail tip briefly and watching for color change

• There is slow (greater than 2 seconds) capillary nail bed refill (return of pink tone) with
respiratory or cardiovascular diseases that cause hypoxia.

VALIDATING AND DOCUMENTING FINDINGS

• Validate your normal and abnormal findings with the client, other health care workers

• Next, document the skin, hair, and nail assessment data that you have collected on the appropriate form.

• Document both normal and abnormal findings. Normal findings can act as a baseline for findings that may
change later.
ANALYSIS OF DATA: DIAGNOSTIC REASONING

• After collecting subjective and objective data pertaining to the skin, hair, and nails, identify abnormal findings
and client strengths using diagnostic reasoning.

• Then, cluster the data to reveal any significant patterns or abnormalities.

SELECTED NURSING DIAGNOSES

Health Promotion Diagnosis

• Readiness for Enhanced Self-Health Management: Skin, hair, and nail integrity related to healthy hygiene and
skin care practices, avoidance of overexposure to sun

Risk Diagnoses

• Risk for Impaired Skin Integrity related to excessive exposure to cleaning solutions and chemicals

• Risk for Imbalanced Body Temperature related to severe diaphoresis

• Risk for Imbalanced Nutrition: Less than body requirements related to increased vitamin and protein
requirements necessary for healing of a wound

Actual Diagnoses

• Ineffective Health Maintenance related to lack of hygienic care of the skin, hair, and nails

• Impaired Skin Integrity related to immobility and decreased circulation

• Disturbed Body Image related to scarring, rash, or other skin condition that alters skin appearance

• Disturbed Sleep Pattern related to persistent itching of the skin

SELECTED COLLABORATIVE PROBLEMS

• Collaborative problems differ from nursing diagnoses in that they cannot be prevented or managed with
independent nursing interventions. However, these physiologic complications of medical conditions can be
detected and monitored by the nurse.

• In addition, the nurse can use physician- and nurse-prescribed interventions to minimize the complications of
these problems.

• The nurse may also have to refer the client in such situations for further treatment of the problem.

• RC: Allergic reaction

• RC: Skin rash

• RC: Skin infection

• RC: Ischemic skin ulcers

• RC: Hemorrhage

MEDICAL PROBLEMS

• After grouping the data, it may become apparent that the client has signs and symptoms that require medical
diagnosis and treatment. Referral to a primary care provider is necessary