Skin, hair, nails assessment

Epidermis

• top layer of skin

• Stratum germinativum/basal cells layer

• Stratum corneum/horny cell layer

• Derivation of skin color

• Protection

What are the epidermal appendages?

• hair

• Sebaceous glands: eccrine and apocrine glands (sweat glands)

• Nails: keratin

Dermis

• inner layer of the skin

• Connective tissue/collagen

• Elastic tissue

Subcutaneous layer

• deepest layer of skin

• Cushions bone and muscle

• Insulation

What are some functions of the skin?

• protection from foreign substances

• Retain fluids/electrolytes

• Perception/sensarion

• Temp regulation

• Absorption/secretion

• Vitamin D production

What are some subjective data-health history questions for assessing skin?

• previous history of skin disease

• Change in mole

• Excessive dryness or moisture

• Hair loss

• Medications

• Rash or lesions

• Self-care behaviors

How do you conduct a physical exam for skin?

• inspect from head to neck to trunk, arms, legs, and back for general color

• Inspect for localized variations of color

What are intentional skin variations of color?

• tattoos

• Coining patterns

What are some normal skin variations of color?

• striae: silver or pink stretch marks

• Vitiligo: unpigmented skin

• Moles (nevi): tan to dark brown, raised or flat, watch for changes

• Freckles: small, flat macules

• Birthmarks: tan, reddish, or brown and flat

What are some abnormal skin variations?

• pallor: pale indicating anemia or shock

• Cyanosis: blue tinge to skin or gray color in lips, indicates lack of oxygen or exposure to cold

• Jaundice: yellow from increased bilirubin, indicated liver disease

• Erythema: red from increased cutaneous blood flow, indicates inflammation, fever, blushing

Objective data for skin assessment

• look for external variables that can influence color (emotions, environment, physical etc)

• Equipment needed: strong lighting, ruler, penlight, gloves

• Temp and moisture

• Texture and thickness

• Turgor

• Edema

• Hair

• Nails

• Capillary refill

Assessing temperature and moisture of the skin

• palpate skin from head to neck to trunk, arms, legs, and back

• Temp: hypo/hyperthermia

• Moisture: warm and dry

Assessing texture and thickness of the skin

• texture: smooth, soft, intact, even surfaces, calluses

• Thickness: varies with age and area, eyelids thinnest, palms/soles thickest, calluses thick from friction/pressure

Assessing turgor of skin

• pinching large fold of skin on anterior chest under clavicle or the hand

• Turgor is the ability of the skin to return to place when releases

• Poor turgor is a sign of dehydration

• Skin recedes or “tents” when released and stands by itself

Assessing edema in the skin

• fluid accumulating in intercellular spaces, not normally present

• Imprint thumb firmly against affected area: normal skin stays smooth, if pressure leaves a dent pitting edema is present

Pitting edema four point grading scale

• 1+ mild pitting: slight indentation, no perceptible swelling

• 2+ moderate pitting: indentation subsides rapidly

• 3+ deep pitting: indentation remains for a short time, swelling is evident

• 4+ very deep pitting: indentation lasts a long time, swelling very evident

ABCDE rule of assessing moles

• Asymmetry: if cut in half are even on both sides

• Border: moles with edges that are jagged

• Color: gaining or losing color or multicolored

• Diameter: more than ½ cm in diameter

• Evolution: changed size, shape, color, or risen

Assessing hair

• inspect and palpate scalp for surface characteristics, distribution, texture, quantity

• Should be smooth without flaking, scaling, lesions

• Should be shiny and soft

• Look for balding patterns and hair loss

Assessing nails

• edges: smooth and rounded

• Shape: flat and slightly rounded

• Consistency: note grooves, depressions, pitting, ridges

• Color: pink, blanched in light skinned clients and yellow/brown with vertical lines in dark-skinned clients

• Profile sign: viewing finger from the side to detect early clubbing

• Capillary refill

What are the angles for a nail profile sign?

• normal angle: 160

• Curved nail: normal when angle is 160

• Early clubbing: angle is 180

• Late clubbing: angle is >180

Assessing capillary refill

• inspect and palpate nails

• Thickness: smooth and uniform

• Inspect for cleanliness

• Depress nail edge to blanch, release, watch color return, normal is <2 seconds