SKIN, HAIR, and NAILS

Assessment
 SUBJECTIVE DATA
1) Past history of skin disease. Any past skin disease or problem?
• How was this treated?
• Any family history of allergies or allergic skin problem?
• Any known allergies to drugs , plants, animals?
• Any birthmarks tattoos?
2) Change in pigmentation. Any change in skin color or pigmentation?
• A generalized color change (all over) or localized?
3) Change in mole. Any change in a mole: color, size, shape, sudden appearance
of tenderness, bleeding, itching? Any “sores” that do not heal?
4) Excessive dryness or moisture. Any change in the feel of your skin:
temperature, moisture, texture? Any excess dryness
5) Pruritus. Any skin itching? Where and when it start? Is this mild ( prickling,
tingling) or intense (intolerable)? Does it awaken you from sleep?
6) Excessive bruising. Any excess bruising? Where on the body?
• How did this happen? How long have you had it?
7) Rash or Lesion. Any skin rash or lesion?
• Onset. When did you first notice it?
• Location. Where did it start?
• Character or quality. Describe the color.
 • Duration. How long have you had it?
• Setting. Anyone at home or work with similar rash? Have you tried a new food,
drug?
• Alleviating and aggravating factors. What home care have you tried? Bath,
lotions? Do they help or make it worse?
• Associated symptoms. Any itching, fever?

8) Medications: Which medications do you take? Prescription and over the

counter?
9) Hair loss. Any recent hair loss? Associated with fever, illness, increased
stress? Any unusual hair growth? Any recent change in texture, appearance?
10) Change in nails. Any change in nails: shape, color, brittleness? Do you tend
to bite or chew nails?

11) Environmental or occupational hazards. Any environmental or

occupational hazards? Recently been bitten by insect? Any recent exposure to
plants, animals?
12) Patient-centered care. What do you do to care for your skin, hair, nails?
Which cosmetics, soaps, chemicals do you use? Do you perform a skin self -
examination?
 OBJECTIVE DATA
Physical Examination
Equipment:
o Examination light
o Small centimeter ruler
o Penlight
o Gloves
o Magnifying glass

Preparation:
Wash hands
Ensure that all the necessary equipment is ready for use and within reach..
Ask the client to put on the examination gown.
Ask the client to remove any items that would interfere with physical
assessment.
 Have the client sit on the examination table or bed.
 Ensure privacy.
 Explain what you are going to do.
 Inspect and Palpate the Skin
1. COLOR
a. General Pigmentation
o Observe the skin tone.
o Normally, it is even and consistent with genetic
background.
o Pinkish tan to ruddy dark tan, light to dark brown, yellow
or olive overtones.
o Common (benign) pigmented areas :
o Freckles
o Mole,
o Birthmarks
DANGER SIGNS: Abnormal characteristics of pigmented
lesions are summarized in mnemonic ABCDE:
Normal

= not regularly round or oval

two halves of lesions do not
look the same

= irregularity ( scalloping,
ragged edges, poorly defined
margins)

= variations ( areas of brown,

tan, black, blue, red, white)

iameter = greater than 6 mm

= elevation
 b. Widespread Color Change
o Note any color change over the entire body such as pallor
(white), erythema (red), cyanosis (blue), and jaundice (yellow).

 Pallor: (white)- Loss of color- is seen in arterial

insufficiency, decreased blood supply, anemia and shock.
 Erythema:(red) intense redness of the skin is from excess
blood in the dilated superficial capillaries. This sign is
expected with fever, local inflammation or emotional
reactions.
 Cyanosis:(blue) bluish mottled color from decreased
perfusion, the tissues have high levels of deoxygenated
blood.
 Jaundice: (yellow) indicates rising amounts of bilirubin in
the blood.
2. TEMPERATURE
o Note the temperature of your own hands.
o Use the backs (dorsa) of your hands to palpate the person and check
bilaterally.
o The skin should be warm, and the temperature should be equal
bilaterally.
3. MOISTURE
o Use the dorsal surfaces of the hands to assess moisture
o Check under skin folds and in unexposed areas.
4. TEXTURE
o Use the palmar surface of your three middle fingers to palpate skin
.
texture.
o Normal skin feels smooth and firm.
o Abnormal skin texture: rough, dry, and flaky.
5. THICKNESS
o Palpate skin to assess thickness.
o Normal: Epidermis uniformly thin over most of the body.
o Abnormal :Very thin, shiny skin (atrophic) occurs with arterial
insufficiency.
6. EDEMA
o It is fluid accumulating in the interstitial spaces;
o It is not present normally.
o To check, imprint your thumbs firmly for 3 to 4 seconds against the
ankle malleolus or the tibia.
o Normally, the skin surface stays smooth.
o If pressure leaves a dent in the skin “pitting edema” is present.

Graded on a four-point scale:

• 1+ MILD Pitting: slight indention,
no perceptible swelling of the leg.
• 2+ MODERATE Pitting:
indentation subsides rapidly
• 3+ DEEP Pitting: indentation
remains for a short time; leg looks
swollen
• 4+ VERY DEEP Pitting:
indentation lasts a long time, leg
is very swollen
7. MOBILITY AND TURGOR
o Mobility is the ease of skin to rise.
o Turgor is its ability to return to
place when released.
o Reflects the elasticity of the skin.
o Pinch up a large fold of skin on the
anterior chest under the clavicle.

8. VASCULARITY or BRUISING
o Inspect the skin for vascularity
• Cherry angiomas are small,
smooth, bright red dots that
commonly appear on the trunk in
all adults older than 30 y/o, and
are not significant.

o Note any bruising ( contusion ).

o Document the presence of any tattoos.
9. LESIONS
1. Note lesions for
• Color
• Elevation: flat, raised
• Pattern or shape: annular, group, confluent, linear
• Size in cm: Use a ruler to measure
• Location and distribution on body: generalized or localized
• Any exudate, its color and odor

2. Palpate lesions
• Wear glove if in contact with blood.
• Roll a nodule between the thumb and index finger to assess
depth.
• Gently scrape a scale if it comes off.
• Note the surrounding skin temperature
• Use a magnifier and light for closer inspection of lesion.
• With the room darkened, use a Wood’s light to detect
fluorescing lesions.
 Inspect and Palpate the Hair
o Inspect hair for general color and condition.
1. COLOR o Hair color comes from melanin production.
o Graying begins as early as 30 y/o.
o Hair may be fine or thick, look straight, curly, or
2. TEXTURE
kinky and looks shiny.
o Abnormal: dull, coarse, brittle

3. DISTRIBUTION
o Fine vellus hair coats the body.
o Coarser terminal hair grows at the eyebrows, eyelashes, and
scalp.
o Hirsutism – excess body hair

4. LESIONS
o Wear gloves if lesions are suspected or if hygiene is poor.
o Separate the hair into sections and lift it, observing the scalp for
any lesions.
o Inspect the hair behind the ears and the occipital area.
 Inspect and Palpate the Nails
1. SHAPE AND CONTOUR
o Inspect shape and contour.
o The Profile Sign: View the index finger at its profile. Note the angle of
the nail base. Normally, it is 160 degrees.
o Normal Findings: nail surface is slightly curved or flat, nail folds are
smooth and rounded, nail edges are smooth, rounded and clean.
o Abnormal findings: jagged nails, clubbing of nails occurs with
congenital cyanotic heart disease, lung cancer, and pulmonary
disease

2. CONSISTENCY
o Palpate nails for consistency.
o Normal: surface is smooth and regular, nail thickness is uniform,
nail firmly adheres to the nail bed, nail base is firm
 3. COLOR
o Normally translucent nail plate and pink nail bed
o Abnormal: cyanosis or marked pallor.
 Test for Capillary Refill:
• Depress the nail edge to blanch.
• Then release, noting the return of color.
• Normally color return is instant or at least
within a few seconds in a cold environment.
• This indicates the status of peripheral
circulation
• A sluggish color return takes longer than 1
or 2 seconds.
• Cyanotic nail beds or slow color return:
consider Cardiovascular or respiratory
dysfunction.

o Inspect the toenails. Separate the toes and note the smooth
skin in between.
o Abnormal: athlete’s foot scaling
 Documentation
Sample Charting

SUBJECTIVE
No history of skin disease; no present change in pigmentation or in nevi;
no pruritus, bruising, rash, or lesions. On no medications. No work-
related skin hazards. Uses SPF 30 sun-block cream when outdoors.

OBJECTIVE
Skin: Color tan-pink, even pigmentation, with no suspicious nevi. Warm
to touch, dry, smooth, and even. Turgor good, no lesions.
Hair: Even distribution, thick texture, no lesions or pest inhabitants.
Nails: No clubbing or deformities. Nail beds pink with prompt capillary
refill.

ASSESSMENT
Warm, dry, intact skin.