Assessment of Hair, Skin, Nails, and Head-to-Toe Review

Assessment Categories and Physiological Concepts

• Perfusion: This is defined as the passage of blood, a blood substitute, or other fluid through the blood vessels or other natural channels in an organ of tissue.

• Gas Exchange: This physical process involves gases moving passively by diffusion across the surface.

• Nutrition: This refers to the process of providing or obtaining the food necessary for health and growth.

• Motion Extremities: Evaluated by moving the extremities.

• Tactile Sensory Perception: This is the brain's ability to understand or perceive information coming from the skin, specifically the skin on the hands.

• Elimination: Assessment includes monitoring for diarrhea or gross incontinence.

• Pain: Evaluated through the observation of facial expressions.

Wound Assessment and Staging

• Stage 1: The skin remains intact with non-blanchable redness, usually located over a bony prominence. The area may feel painful, firm, soft, warm, or cooler compared to surrounding tissue. This stage may be difficult to detect in individuals with dark skin.

• Stage 2: This involves partial-thickness loss of the dermis. It presents as a shallow, open ulcer with a pink wound bed that is either shiny or dry, without sloughing or bruising. It may also present as an intact or open/ruptured serum-filled blister.

• Stage 3: Full-thickness tissue loss involving damage to or necrosis of subcutaneous tissue. Subcutaneous fat may be visible ($3 = \text{fat}$), but bone, tendon, and muscle are not exposed. Slough may be present. This stage may requires assessment for tunneling.

• Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle ($4 = \text{bone}$). Slough or eschar may be present in the wound bed. Undermining and tunneling are usually present.

• Unstageable: Full-thickness tissue loss where the true depth of the wound cannot be determined because the base is covered in slough ($yellow$, $tan$, $gray-green$, or $brown$) and/or eschar ($tan$, $brown$, or $black$). The depth cannot be confirmed until enough slough/eschar is removed to expose the wound base.

• Deep Tissue Pressure Injury: This presents as a localized area of purple or maroon discoloration of intact skin or a blood-filled blister ($purple = \text{Deep}$). It is caused by damage to underlying soft tissue from pressure or shear.

• Barrier Cream: These creams protect the skin from moisture (urine, stool, excess moisture) to help prevent skin breakdown.

Primary and Secondary Skin Lesions

• Primary Skin Lesions (starting on the skin):

  • Macule: A small, flat spot ($M = \text{Mark}$).

  • Patch: A large, flat spot ($\text{Patch} = \text{big flat mark}$).

  • Papule: A small, solid bump ($\text{P} = \text{pimple}$).

  • Plaque: A large raised area ($\text{Plaque} = \text{Plateau}$).

  • Nodule: A hard, deeper lump ($\text{N} = \text{knot}$).

  • Wheal: A raised, itchy swelling ($\text{W} = \text{Welt/Hives}$).

  • Vesicle: A small blister containing clear fluid ($\text{V} = \text{very small blister}$).

  • Bulla: A big blister containing clear fluid ($\text{B} = \text{big blister}$).

  • Pustule: A bump filled with pus.

  • Cyst: A sac-like lump filled with fluid.

• Secondary Skin Lesions (changed or damaged skin):

  • Scale: Flaky skin, similar to fish scales.

  • Crust: Dried blood or fluid, also known as a scab.

  • Fissure: A crack in the skin.

  • Erosion: Shallow skin loss.

  • Excoriation: A scratch mark.

  • Scar: Healed damaged skin.

  • Keloid: A thick, raised scar.

  • Ulcer: Deep skin loss or an open sore.

  • Lichenification: Thick skin resulting from repeated scratching.

  • Atrophy: Thinning of the skin.

ABCDE Rule for Melanoma Assessment

• A (Asymmetry): One half of the spot does not match the other ($\text{A} = \text{uneven sides}$).

• B (Border): The edges of the spot are irregular, ragged, notched, or blurred ($\text{B} = \text{bad border}$).

• C (Color): The color is not uniform; it may include multiple colors or shades ($\text{C} = \text{Colors/weird edges}$).

• D (Diameter): The spot is larger than $6\,mm$, which is roughly the size of a pencil eraser ($\text{D} = \text{diameter}$).

• E (Evolving): The mole is changing in size, shape, or color ($\text{E} = \text{Evolving/Change}$).

Skin Cancer Risks and Prevention

• Risk Factors:

  • Excessive sun or UV exposure, including repeated sunburns and tanning bed use.

  • Fair skin, light-colored eyes, or hair color that burns or freckles easily.

  • Having many or unusual moles.

  • Personal or family history of skin cancer.

  • Older age due to more lifetime UV exposure.

  • Weakened immune system or immunosuppression.

  • Exposure to certain chemicals or radiation.

• Prevention Recommendations:

  • Apply sunscreen with $\text{SPF } 30+$ or higher.

  • Avoid the sun during the strongest hours.

  • Wear protective clothing, including hats.

  • Avoid tanning beds.

  • Regularly check the skin and report any molecular changes to a provider.

Vascular Lesions and Systemic Discoloration

• Petechiae: Tiny red or purple dots representing very small bleeding under the skin ($\text{P} = \text{pinpoint}$).

• Purpura: Purple spots larger than petechiae involving bleeding under the skin ($\text{Purpura} = \text{purple}$).

• Ecchymosis: A large purple or blue area, commonly known as a bruise ($\text{E} = \text{extra large bruise}$).

• Cherry Angioma: A small, bright red, round, raised spot. These are benign blood-vessel growths and are common in older patients.

• Jaundice: Yellowing caused by increased bilirubin.

  • Light Skin: Look for yellowing in the skin and the sclera (white of the eyes).

  • Dark Skin: Look for yellowing in the sclera, the inside of the mouth (oral mucosa), and the palms of the hands and soles of the feet.

• Cyanosis: A bluish or gray color resulting from decreased oxygenation.

  • Light Skin: Visible in the lips, nail beds, and general skin.

  • Dark Skin: Look for an ashen/gray coloring; blue may be harder to see. Check the lips, inside of the mouth, conjunctiva, palms, and nail beds.

Nail Assessment and Findings

• Normal Nails: These should feel smooth and firm. They should be slightly curved with a nail base angle of about $160^\circ$. Capillary refill should be measured.

• Clubbing: Characterized by rounded, bulging fingertips and a nail angle greater than $180^\circ$. This indicates chronic low oxygen (hypoxia).

• Spoon Nails (Koilonychia): The nail curves inward like a spoon; this can indicate iron deficiency anemia.

• Brittle Nails: Nails that crack or break easily, often linked to nutritional or health problems.

• Thick/Yellow Nails: Often indicates a fungal infection.

• Capillary Refill: Normal is < 2\,seconds. A delayed refill of > 2\,seconds suggests poor peripheral circulation.

Head, Neck, and Neurological Assessment

• Lumps: A lump measuring $5\,cm$ or less is a nodule; a lump measuring $6\,cm$ or more is considered a tumor.

• Migraines: Severe headaches characterized by specific symptoms:

  • Nausea and vomiting.

  • Sensitivity to light.

  • Visual disturbances known as Auras (flashing lights, zig-zag lines, spots, blind spots, blurry/changed vision).

• Sinus Infection: Typically presents with thick yellow or green nasal drainage, sinus pressure/pain, and nasal congestion.

• Cerebellar Function (Romberg Test): The patient stands with feet together and eyes closed. A slight sway is considered normal ($\text{Slight sway} = \text{OK}$). Losing balance or excessive swaying is abnormal.

• Post-Accident Evaluation: In the event of a car accident, irregular or slurred speech is a major concern as it can indicate a brain injury or neurological problem.

• Orientation: To assess mental status, check for the four dimensions of orientation: Person (Who are you?), Place (Where are you?), Time (What is the date/year?), and Situation (Why are you here?). This is documented as $A \text{ and } O$.

• PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation. This is primarily associated with Cranial Nerve III.

Cranial Nerves (CN)

• CN I (Olfactory): Sense of smell.

• CN II (Optic): Vision. Tested using the Snellen Chart for visual acuity (how clearly one sees) and the Confrontation Test for visual fields (peripheral vision).

• CN III (Oculomotor): Eye movement, pupil constriction. Part of the eye tricks ($3, 4, 6$) and PERRLA.

• CN IV (Trochlear): Eye movement (down and in).

• CN V (Trigeminal): Facial sensation and chewing ($\text{Tri} = 3\text{ areas of the face}$).

• CN VI (Abducens): Eye movement (outward).

• CN VII (Facial): Facial expressions and taste. Tested by asking the patient to smile, frown, puff cheeks, or raise eyebrows.

• CN VIII (Vestibulocochlear): Hearing and balance. Tested using the whisper test, standing slightly to the right or left of the patient (not behind) while they cover one ear.

• CN IX (Glossopharyngeal): Taste and swallowing.

• CN X (Vagus): Controls heart, lungs, and digestion; "wanders" through the body.

• CN XI (Accessory): Shoulder shrugging and head turning ($11 = 2\text{ shoulders}$).

• CN XII (Hypoglossal): Tongue movement.

Examination Observations and Normals

• Pupil Responses:

  • Direct Response: The eye receiving the light constricts.

  • Consensual Response: Both pupils constrict together when light is shined into only one eye.

• Nose: Normal turbinates are deep pink, moist, and free of swelling or abnormal drainage.

• Skin WNL: Warm, dry, intact, appropriate color for ethnicity, good skin turgor (springs back quickly), and no excessive edema or unusual lesions.

• Normal Variations: Freckles, gray hair, birthmarks, and wrinkles or baldness related to aging or genetics.

• Hair WNL: Evenly distributed, clean scalp, no lice, and no unusual hair loss.

Respiratory Assessment and Terminology

• Lung Sounds:

  • Rhonchi: Low-pitched snoring sounds heard during inhalation, usually caused by mucus in large airways; may clear with coughing.

  • Wheezing: High-pitched, musical sounds usually heard during expiration, caused by narrowed airways.

  • Crackles: High-pitched popping or crackling sounds heard during respiration, often caused by fluid in the small airways (alveoli).

  • Stridor: High-pitched squeaking sound caused by an upper airway obstruction; usually louder on inspiration.

• General Evaluation: Never listen to lung sounds over clothing. Watch for signs of respiratory distress: Anxiety, restlessness, and nasal flaring.

• Terms:

  • Bradypnea: Slow breathing (< 8\,breaths/min).

  • Tachypnea: Fast breathing (> 20\,breaths/min).

  • Mal: Bad or malignant.

  • -ectomy: Surgical removal (e.g., prostatectomy).

  • -ostomy: Creating an opening from the inside of the body to the outside.

  • Hemoptysis: Coughing up blood.

Mental Health and Substance Abuse

• Subjective Data: What the patient says (e.g., "I feel sad," "I am anxious," "I can't sleep," "I hear voices").

• Objective Data: What the nurse observes (e.g., crying, poor eye contact, pacing, shaking/trembling, disheveled appearance, flat facial expression).

• Substance Use Assessment: Maintain a nonjudgmental attitude, ensure privacy and confidentiality within legal/safety limits, and build trust. Assess grooming, facial expressions, and orientation.

• Denial: Refusal to accept the presence of a problem.

Clinical Mathematics

• Rounding to the Nearest Whole Number: Check the first decimal place.

  • $0-4 \rightarrow \text{Round down}$

  • $5-9 \rightarrow \text{Round up}$

  • Examples: $7.4 \rightarrow 7$; $7.5 \rightarrow 8$; $12.8 \rightarrow 13$.

• Unit Conversions ($mcg \leftrightarrow mg$):

  • $1\,mg = 1,000\,mcg$

  • To get mg from mcg: $\text{Value} \div 1,000$ (e.g., $500\,mcg \div 1,000 = 0.5\,mg$).

  • To get mcg from mg: $\text{Value} \times 1,000$ (e.g., $2\,mg \times 1,000 = 2,000\,mcg$).

• Percentages: Convert the percentage to a decimal (e.g., $30\% = 0.30$) and multiply.

  • Example: If a patient has $90$ tablets and can only pay for $30\%$, they receive $90 \times 0.30 = 27$ tablets. The remainder is $90 - 27 = 63$ tablets.