Skin, Hair, and Nails Assessment Study Notes
Skin, Hair, and Nails Assessment
Structure and Function of the Skin
Layers of the Skin
Epidermis
Contains two main layers:
Stratum germinativum (Basal Cell Layer): Deepest layer, where cell division occurs.
Stratum corneum (Horny Cell Layer): Outer layer, consisting of dead cells that shed off.
Derivation of Skin Color: Influenced by melanin, carotene, and blood flow.
Dermis:
Composed of connective tissue (collagen) and elastic tissue, providing strength and elasticity to the skin.
Subcutaneous Layer:
Composed mainly of fat and connective tissue, supports and insulates the body.
Epidermal Appendages
Types of Appendages:
Hair
Sebaceous Glands: Produce oil (sebum) that lubricates the skin and hair.
Sweat Glands:
Eccrine Glands: Regulate body temperature by releasing sweat.
Apocrine Glands: Associated with body odor, located in areas with hair follicles.
Nails: Composed of keratin, providing protection and support.
Functions of the Skin
Main Functions:
Protection: Shield against microbial and foreign substance invasion.
Prevention of Penetration: Acts as a barrier to water and pathogens.
Retention of Fluid and Electrolytes: Maintains hydration.
Perception/Sensation: Contains nerve endings for touch, temperature, and pain.
Temperature Regulation: Manages body temperature through sweat and blood flow.
Identification: Contributes to personal and biological identification.
Communication/Emotion: Expresses emotions through skin changes (e.g., blushing).
Wound Repair: Facilitates healing and regeneration of tissues.
Absorption and Excretion: Involved in waste removal through sweat.
Production of Vitamin D: Engages in the synthesis of vitamin D when exposed to sunlight.
Subjective Data— Health History Questions: Skin
Key Questions for Assessment:
Previous history of skin diseases (e.g., allergies, hives, psoriasis, eczema).
Change in mole characteristics.
Change in pigmentation (size or color).
Symptoms of excessive dryness or moisture.
Presence of pruritus (itching).
Excessive bruising or unusual rash/lesion.
Medications currently being taken.
Hair loss or alterations in nail structure.
Environmental or occupational hazards.
Self-care behaviors regarding skin care.
Objective Data— The Physical Exam: Skin
Preparation for Examination:
Account for external variables influencing skin color such as emotions, environment, and physical state.
Equipment Needed:
Strong direct lighting.
Small centimeter ruler.
Penlight for illumination.
Gloves to ensure hygiene during examination.
Inspection Process:
Systematically inspect the skin from head to neck, trunk, arms, legs, and back observing general color and uniformity.
Skin color ranges designed to assess conditions:
Whitish pink to olive tones to deep brown.
Note that sun-exposed skin is typically darker.
Localized variations to be inspected include intentional markings (tattoos), normal localized variations (pigmented nevi, freckles, patches), and striae (stretch marks).
Normal Skin Variations
Key Normal Variations:
Striae: Silver or pink “stretch marks”.
Vitiligo: Areas of unpigmented skin.
Moles (Nevi): Range from tan to dark brown, can be raised or flat; monitored for changes.
Freckles: Small, flat macules.
Birthmarks: Flat, can be tan, reddish, or brown.
Abnormal Skin Findings
Indicators of Abnormal Skin:
Pallor: Pale skin; can indicate anemia or shock.
Cyanosis: Blue or gray tinge; typically indicates lack of oxygen or exposure to cold.
Jaundice: Yellowing skin due to increased serum bilirubin; often indicates liver disease.
Erythema: Red discoloration; suggests increased blood flow from inflammation, fever, or blushing.
Skin Color Changes
Color Changes in Light Skin:
Pallor: Appears white or pale.
Erythema: Results in red or bright pink appearance.
Cyanosis: Presents as dusky blue.
Jaundice: Yields yellow coloration, can also affect sclera and palate.
Color Changes in Dark Skin:
Pallor: Appears yellowish-brown or ashen gray.
Erythema: Manifests as purplish tint.
Cyanosis: Appears as dark, dull, and lifeless.
Jaundice: Visible in sclera and hard/soft palate junction; also on palms of hands.
Objective Data— The Physical Exam: Skin Palpation
Palpation Process:
Systematically palpate skin from head to neck, trunk, legs, arms, and back.
Assessments Include:
Temperature:
Check for hypothermia (low temperature) or hyperthermia (high temperature).
Moisture:
Evaluate warmth and dryness; monitor for diaphoresis (excessive sweating) and signs of dehydration.
Skin Texture and Thickness
Consistency Assessment:
Check skin texture: should be smooth, soft, and intact with even surface.
Note any calluses on hands, feet, elbows, or knees.
Thickness Variations:
Thinnest on eyelids, thickest on palms and soles.
Calluses indicate thickened skin due to friction and pressure.
Skin Mobility and Turgor Assessment
Mobility Testing:
Pinching a fold of skin on the anterior chest or hand to check easiness of rise.
Turgor Assessment:
Refers to the skin's ability to return to place promptly after being released; poor turgor suggests dehydration.
A tenting effect where the skin recedes slowly is indicative of dehydration.
Edema Evaluation
Definition of Edema:
Fluid accumulation in intercellular spaces; normally not present.
Assessment Method:
Imprint the thumb against the ankle malleolus and tibia; skin should remain smooth.
If pressure leaves a dent, pitting edema is present.
Pitting Edema Grading Scale:
1+ Mild Pitting: Slight indentation; no visible swelling.
2+ Moderate Pitting: Indentation subsides rapidly.
3+ Deep Pitting: Indentation remains briefly; leg appears swollen.
4+ Very Deep Pitting: Indentation lasts a long time; significant swelling.
Assessment of Moles: ABCDE Criteria
ABCED of Moles:
Asymmetry: Moles that are not symmetrical when divided in half.
Border: Irregular edges; jagged resemblance.
Color: Changes in color or multicolored patches.
Diameter: Moles larger than 0.5 cm, especially with uneven color.
Evolution: Moles that alter in size, shape, color, or elevation.
Objective Data— The Physical Exam: Hair
Hair Assessment:
Inspect and palpate scalp and hair for:
Surface Characteristics: Should be smooth; no flaking, redness, or lesions.
Shininess and Softness: Healthy hair appears shiny and soft.
Quantity and Distribution: Note any balding patterns, hair loss types (e.g., male pattern baldness).
Texture and Color: Examine facial and body hair for similar aspects.
Objective Data— The Physical Exam: Nails
Nail Examination: Inspect and palpate nails for:
Edges: Should be smooth and rounded.
Shape and Contour: Generally flat and slightly rounded.
Consistency: Look for grooves, depressions, pitting, or ridges in nails.
Color: Nails should appear pink in light-skinned individuals, with yellow/brown vertical lines in dark-skinned individuals.
Profile Sign: Nail Clarity
Profile Sign Method:
View nail from the side to detect clubbing.
Normal angle of nail base should be 160°.
Curved Nail: Normal when maintaining this angle at 160°.
Early Clubbing: Angle may be 180° (a straight line).
Late Clubbing: Angle surpasses 180°.
Nail Inspection Illustrations
Clubbing Visualization:
Clubbing Characteristics
A. Normally when fingers oppose, a small space is present.
B. With finger clubbing, the angle between nails diverges and no space remains.
C. The base of the nail expands and curves in clubbing.
Objective Data— The Physical Exam: Nails continued
Further Nail Assessment: Inspect and palpate nails for:
Thickness: Should be smooth and uniform.
Cleanliness: Ensure nails are clean.
Capillary Refill Test:
Depress nail edge to cause blanching, release, and observe color return.
Normal capillary refill time is less than 2 seconds.