Skin, Hair, Nails

Identify correct technique and order of performing a skin, hair, nails assessment.

Objective Assessment: What we collect

DO FIRST: General Survey (quick glance at pt) prior to systematic approach

Skin

  • Inspect skin of each body area in a head to toe approach

    • Eyes, lips, inside of mouth — Dehydration, cancers

    • Focus on areas prone to skin breakdown and moisture

    • Use ABCDE format for any lesions (melanoma signs)

      • Asymmetry, Border, Color, Diameter, Evolving

    • Inspect wounds (Describe and stage wound healing)

  • Palpate skin

    • Temperature

    • Skin turger (normal is less than 4 seconds; inner thigh for elders 65+)

    • Edema

Hair

  • Note hair texture, hygiene, lesions, nits

  • Hair styles

  • Don’t forget behind ears and at base of scalp (lice breakdown, etc.)

Nails

  • Inspect then palpate fingernails and toenails

    • Capillary refill (normal is <2 seconds)

    • Nail angle (normal is <160 degrees)

Analyze and interpret patterns in laboratory and diagnostic findings to identify patterns and individualize patient assessment.

Complete Blood Count (CBC)

Red Blood Cell (RBC) Count: Total # of RBCs in a sample

Hemoglobin (HGB): Amount of Hgb in a sample

Hematocrit (HCT): % of total blood volume made up of RBCs

RBC Morphology: Examination of size, shape, color, and structure of RBCs

Platelet Count (PLT): # of platelets in a sample to clotting capacity and bone marrow function

Platelet Size

White Blood Cell (WBC) Count: Total # of leukocytes in a sample

Basic Metabolic Panel (BMP) — Electrolytes & Renal Function Indicators

Sodium (Na+)

Chloride (Cl-)

Potassium (K+)

Blood Urea Nitrogen (BUN): Measures amount of nitrogen in the blood that comes from urea to evaluate kidney function (healthy kidneys filter urea from blood)

Creatinine: Level of waste products created by muscle metabolism, which kidneys typically filter out

Glomerular Filtration Rate (GFR): How well your kidneys filter waste

Calcium (Ca2+)

Glucose

Braden Scale

Definition: Tool to determine patient’s risk of skin breakdown

Possible High Score: 23 points

Six Criteria: Sensory perception, moisture, activity, mobility, nutrition, friction & shear

Would Healing Phases

  • Inflammatory Phase

  • Proliferative Phase — “Ground beef” granules

  • Remodeling Phase (Takes weeks to years)

Describe normal and abnormal findings using appropriate medical terminiology.

Common Skin Findings

Primary Skin Lesions

Definition: Abnormalities appearing on previously healthy skin

Macule (<1 cm; flat discolorations, freckles) vs. Papule (<1 cm; raised and defined bumps, insect bites)

Vesicle (Small/<1 cm; fluid-filled) vs. Bulla (Large/>1 cm; fluid-filled)

Patch (Flat color change) vs. Plaque (Textured and raised color change)

Wheal (Raised satellites; well circumcised)

Pustule (<1 cm; pus-filled) vs. Cyst (>1 cm; pus-filled & mobile)

Pustular Acne vs. Cystic Acne

Secondary Skin Lesions

Definition: Develop from these primary lesions or result from external factors

Keloid: Painful scares that have excessive proliferation; common with POC

Scars

Atrophy: Thin appearing, fragile skin

Exoriation: Scratching/rubbing

Distributions/Patterns of Lesions

Asymmetrical (Solely on one side) vs. Symmetrical (Bilateral)

Diffuse (Distributed widely across an affected area w/o any pattern) vs. Generalized (Distributed over one area)

Localized (Located in a distinct area) vs. Grouped (Multiple lesions/wounds in a distribution/pattern)

Cultural Variation

Café au Lait — Born with it and won’t outgrow; common in Asian descent and POC

Congenital Dermal Melanocytosis — Appears as bruising; commin in babies of color

Stork Bites

Cultural Considerations

Important Notes: Treat, educate yourself (cultural values), and educate the patient.

Traction Alopecia — Hair loss related to certain tight hairstyles

Pseudofolliculitis Barbae — Typically found in Black, Hawaiian, and API; patient education on shaving close to skin and going to barbers

Cupping and Coining (tx to promote circulation)

Determine pertinent information that needs to be obtained during the subjective assessment.

Subjective Assessment: What the pt tells you

Areas of Focus

  • Issues (follow up with OLDCARTS)

  • Life changes

  • PMH (past med hx)

  • FH (fam hx)

  • Medications

  • Allergies and severity at exposure

  • Lifestyle (diet, occupation, hygiene, mobility, etc.)

O — Onset

L — Location

D — Duration

C — Characteristics

A — Aggrivating/alleviating

R — Related sxs

T — Tx by pt

S — Severity (pain scale; “How bad is it?”)

Synthesize data from chart review, subjective and objective assessment, to identify patterns or altered concepts, recognize cues and generate solutions/take action.

Oxygenation

Definition: The process of providing oxygen to all cells of the body through adequate gas exchange

Hypoxemia: Decreased oxygen in the blood

Hypoxia: Decreased delivery of oxygen to the tissues

Recognize Cues

  • Clubbing of nails (Chronic finding of hypoxemia)

  • Cyanosis (Late sign of hypoxia; blue in lighter skin tones, gray/green in darker skin tones)

Generate Solutions/Take Action

  • Elevate HOB (head of bed) to open airways & ↓ lung pressure via gravity

  • Administer supplemental O2 (w/ ↓ PaO2 stats)

  • Treat underlying causes

Perfusions

Definition: The physiological process of the heart transporting and distributing a continuous supply of blood throughout the body

Ischemia: Decreased supply of blood and nutrients to the tissues

Infarction: The death of cells due to lack of nutrients/oxygen due to blood flow

Local

  • Cool

  • Pallor of area

  • Pain or ↓ sensation

  • Week or absent pulses

  • Non-blanching skin

  • No hair growth on extremities (chronic)

Systemic

  • Pallor: Loss of color (anemia or poor oxygenation)

  • Cold, clammy skin — Blood is warm; cold = no blood

  • Diaphoresis (sweat) — Compensatory mechanism from ↑ cardiac workload (↑ HR)

  • Capillary refill >2 sec

Pressure Ulcers (Concept Altered: Localized Perfusion)

Stage 1: Red, unblanching area of skin. Skin remains intact.

Stage 2: Partial thickness of loss of dermis.

Stage 3: Full thickness tissue loss. Subcutenous fat may be visible but NO bone, tendon, or muscle.

Stage 4: Full thickness tissue loss. Bone, tendon, OR muscle exposed.

Generate Solutions/Take Action

  • Picture in chart

  • Document in EMR

  • Q2H turns

  • Wound dressing

  • Encourage nutrition (↑ protein & caloric intake)

  • Pressure relieving mattress

  • Ensure lines & drains aren’t under pt

  • Soft nasal canula (ear/nose ulcer risk)

  • Wound care consult (early for prevention)

  • File incident report if nosocomial

Inflammation

Definition: The body’s natural immune response to tissue damage or foreign organisms/particles, including environmental stressors (not just infection!)

Recognize Cues

  • Elevated WBC (if infxn)

  • Erythema

  • Edema

  • Warmth at site

  • Purulent exudate (if infxn)

  • ↑ temp

Generate Solutions/Take Action

  • Determine if due to infxn

  • Wound dressing

  • Hand hygiene

Cellulitis (Concept Altered: Inflammation)

Definition: Skin infxn caused by bacteria or foreign substance in/on epidermis

Recognize Cues

  • Erythema

  • Hot/warm to touch

  • Edema

  • May be painful or itchy

Generate Solutions/Take Action

  • Hand hygiene

  • Monitor s/s of infxn progression

  • Elevate extremity (pain management)

  • Moist heat (penetrates better)

  • Wound dressing

  • IV ABX (fast acting!)

  • Encourage nutrition to fight infxn

Fluid & Electrolyte Balance

Definition: The pattern of equilibrium between fluid volume and chemical composition of body fluids

Recognize Cues

Fluid Volume Excess

  • Edema

  • Weight gain

Fluid Volume Deficit

  • Dry skin & mucous membranes

  • Low BP (1st tx = fluids)

  • Poor skin turgor (dehydration)

Generate Solutions/Take Action

  • Determine & treat underlying cause

  • Monitor (edema)

Burns (Concept Altered: Inflammation, Fluid & Electrolyte Imbalance, Perfusion)

Recognize Cues

  • ↓ Hgb/HCT (losing RBCs)

  • ↓ sodium (fluid loss fm interstitial space damage)

  • ↑ potassium (cell damage pushes K out r/t cardiac issues)

  • ↑ BUN (kidney filtration probs)

  • Erythema

  • Blistering

  • Non-blanching skin

Generate Solutions/Take Action

  • ABC’s (Airway, Breathing, Circulation) ⭐️⭐

  • Remove restrictive clothing (swelling)

  • IV fluids (cell leakage)

  • Wound care

  • Pain ctrl

  • High-calorie, high-protein drinks once able to eat

Dehydration (Concept Altered: Fluid Volume Deficit and Potential for Decreased Perfusion)

Recognize Cues

  • ↑ RBC, HGB, & HCT

  • ↑ BUN/Creatinine (b/c more stuff for kidneys to filter out)

  • Dry skin & mucous membranes

  • ↓ BP (late signs)

  • Poor skin turgor (tenting)

  • ↓ capillary refill

Generate Solutions/Take Action

  • Determine cause

  • Administer IV fluids

  • Monitor electrolytes

  • Encourage oral fluids