HEALTH ASSESSMENT

1. Assessment of Skin, Hairs & Nails
Ms. Gulshan Umbreen
Lecturer, SNC
PhD Scholar (Epidemiology & Public
Health)

2. Learning Objectives
• At the end, Learner will be able to:
• Describe the components of Health History that
should be elicited during assessment of Skin,
Hairs & nails
• Enlist Equipment’s needed for Physical
Examination of Skin, Hairs & Nails
• Explain Types of Skin Lesion
• Explain Characteristics of Skin Lesion
• Explain Stages of Pressure Ulcer

3. • Define different terms related to Nails
• Define different terms related to Hairs

4. SKIN STRUCTURE

5. The Major Functions of the Skin
• Perceiving touch, pressure, temperature, and pain
via the nerve endings
• Protecting against mechanical, chemical, thermal,
and solar damage
• Protecting against loss of water and electrolytes
• Regulating body temperature

6. • Repairing surface wounds through cellular
replacement
• Synthesizing vitamin D
• Allowing identification through uniqueness of
facial contours, skin and hair color, and
fingerprints

7. NAILS
• Thin Plates of Keratinized Epidermal Cells That
Cover the Distal Ends of Fingers and Toes

8. HAIRS
• Thin Fiber Compound of Dead Keratinized
Cells
– Vellus
– Terminal

9. Health History
• Before assessing the skin, ask the patient about
the presence of lesion, rashes, or bruises and
determined whether the alterations are linked to
heat, cold, and stress, exposure to toxic materials
or the sun, or new skin care products. Also
determined if there has been a recent change in
skin color or trauma to the skin.

10. • If a patient has been out in the sun, it is useful to
know if the patient wore sunscreen. If not, the
patient will require education on ways to
safeguard the skin. Also assess for history of
allergies, use of topical medications, and a family
history of serious skin disorders

11. Important Topics for Health Promotion and
Counseling
• Counsel patients to avoid unnecessary sun
exposure, and to use sunscreen with at least SPF-
15.
• Teach the ABCDE screen for dysplastic
nevi/melanomas: Asymmetry, irregular Borders,
variation in Color, Diameter ≥6 mm, and
Evolution or change in size, symptoms, or
morphology.

12. • Survey skin at 3-year intervals for patients 20 to
40 years of age and annually for patients older
than 40 years. For those older than age 50 or with
dysplastic nevi or history of melanoma,
encourage monthly self-examination and do
regular clinical screening

13. HISTORY OF PRESENT HEALTH
CONCERN
QUESTIONS RATIONAL
• Are you experiencing any current skin
problems such as rashes, lesions,
dryness, oiliness, drainage, bruising,
swelling, or increased pigmentation?
What aggravates the problem? What
relieves it?
Any of these symptoms may be related to
a pathologic skin condition.
Bruises, or burns may indicate accidents
or trauma or abuse.
• Describe any birthmarks or moles you
now have. Have any of them changed
color, size, or shape?
A change in the appearance or bleeding
of any skin mark, especially a mole, may
indicate cancer.
Asymmetry, irregular borders, color
variations, diameter greater than 0.5 cm,
and elevation are characteristics of
cancerous
lesions

14. • Have you noticed any change in your
ability to feel pain, pressure,
light touch, or temperature changes? Are
you experiencing any pain, itching,
tingling, or numbness?
Changes in sensation may indicate
vascular or neurologic problems
such as peripheral neuropathy related to
diabetes mellitus
Sensation problems may put the
client at risk for developing pressure
ulcers
• Do you have trouble controlling body
odor? How much do you perspire?
Uncontrolled body odor or excessive or
insufficient perspiration may indicate an
abnormality with the sweat glands or an
endocrine problem such as
hypothyroidism or hyperthyroidism.
Poor hygiene practices may account for
body odor, and health education may be
indicated.

15. • Do you have any body piercings or
tattoos?
Piercing needles place clients at risk for
infection. Tattooing pigments can cause
allergic reactions
• Hair and Nails
Have you had any hair loss or change in
the condition of your hair? Describe.
Patchy hair loss may accompany
infections, stress, hairstyles
that put stress on hair roots, and some
types of chemotherapy.
Generalized hair loss may be seen in
various systemic illnesses
such as hypothyroidism and in clients
receiving certain types of
chemotherapy or radiation therapy.
• Have you had any change in the
condition or appearance of your nails?
Describe.
Nail changes may be seen in systemic
disorders such as malnutrition
or with local irritation (e.g., nail biting).

16. PAST HEALTH HISTORY
• Describe any previous problems with
skin, hair, or nails, including any
treatment or surgery and its
effectiveness.
Current problems may be a
recurrence of previous ones. Visible
scars may be explained by previous
problems.
• Have you ever had any allergic skin
reactions to food, medications, plants, or
other environmental substances?
Various types of allergens can
precipitate a variety of skin eruptions.
• Have you had a fever, nausea, vomiting,
gastrointestinal (GI), or respiratory
problems?
Some skin rashes or lesions may be
related to viruses or bacteria.
• For female clients: Are you pregnant?
Are your menstrual periods regular?
• Do you have a history of anxiety,
depression, or any psychiatric problems?
Some skin and hair conditions can
result from hormonal imbalance.
Depression often occurs in
association with dermatologic disease

17. FAMILY HISTORY
• Has anyone in your family had a
recent illness, rash, or other
skin problem or allergy? Describe.
Acne and atopic dermatitis tend to be
familial. Viruses (e.g., chickenpox,
measles) can be highly contagious. Some
allergies may be identified from family
history
• Has anyone in your family had skin
cancer?
A genetic component is associated with
skin cancer, especially malignant
melanoma
• Do you have a family history of
keloids?
Ear piercing, if desired, should be
performed before age 11 if
there is a history to avoid keloid
formation
• Do you sunbathe? How much sun
exposure do you get? What type of
protection do you use?
Sun exposure can cause premature aging
of skin and increase the risk of cancer.
Hair can also be damaged by too much
sun.

18. • Do you spend long periods of time
sitting or lying in one position?
Older, disabled, or immobile clients who
spend long periods of time in one position
are at risk for pressure ulcers.
• Have you had any exposure to extreme
temperatures?
Temperature extremes affect the blood
supply to the skin and can
damage the skin layers. Examples include
frostbite and burns.
• What is your daily routine for skin,
hair, and nail care? What products do
you use (e.g., soaps, lotions, oils,
cosmetics, razor type, hair spray,
shampoo, coloring, nail enamel)? How
do you cut your nails?
• What kinds of foods do you consume
in a typical day? How much fluid do
you drink each day?
Regular habits provide information on
hygiene and lifestyle. The products used
may also be a cause of an abnormality.
Improper nail-cutting technique can lead
to ingrown nails or infection.
A balanced diet is necessary for healthy
skin, hair, and nails.
Adequate fluid intake is required to
maintain skin elasticity.
LIFESTYLE AND HEALTH PRACTICES

19. Describe any skin disorder that
prevents you from enjoying
your relationships.
Skin, hair, or nail problems,
especially if visible, may impair the
client’s ability to interact comfortably
with others because of embarrassment
or rejection by others
How much stress do you have in your
life? Describe.
Stress can cause or exacerbate skin
abnormalities.
Do you perform a skin self-
examination once a month?
If clients do not know how to inspect
the skin, teach them how to recognize
suspicious lesions early

20. Preparing the Client
• To prepare for the skin, hair, and nail
examination, ask the client to remove all clothing
and jewelry and put on an examination gown.
• In addition, ask the client to remove nail enamel,
artificial nails, wigs, toupees, or hairpieces as
appropriate.
• Have the client sit comfortably on the
examination table or bed for the beginning of the
examination.
• The client may remain in a sitting position for
most of the examination

21. • However, to assess the skin on the buttocks and
dorsal surfaces of the legs properly, the client may
lie on her side or abdomen.
• During the skin examination, ensure privacy by
exposing only the body part being examined.
Make sure that the room is a comfortable
temperature. If available, sunlight is best for
inspecting the skin.
• Explain what you are going to do, and answer any
questions the client may have. Wear gloves when
palpating any lesions because you may be
exposed to drainage.

22. EQUIPMENT’S
• Examination light
• Penlight
• Mirror for client’s self-examination of skin
• Magnifying glass
• Centimeter ruler
• Gloves
• Wood’s light

23. • Examination gown or drape
• Braden Scale for Predicting Pressure Sore Risk
• Pressure Ulcer Scale for Healing (PUSH) tool to
measure pressure ulcer healing

25. PUSH TOOL

26. SKIN
• Examine the entire skin surface Under good lighting.
• Inspect and palpate any Growths
• Note:
Examination Techniques Possible findings
Color
● Moisture
● Temperature
● Texture
Cyanosis, jaundice, carotenemia,
changes in melanin
Dry, oily
Cool, warm
Smooth, rough
● Mobility—ease with which a
fold of skin can be moved
● Turgor—speed with which the
fold returns into place
Decreased if edema
Decreased if dehydration

27. Note any lesions and their:
● Anatomical location and
distribution
● Patterns and shapes
● Type
● Color
Generalized, localized
Linear, clustered, dermatomal
Macule, papule, pustule, bulla,
tumor
Red, white, brown, heliotrope

28. • Inspecting the palms is an opportunity to
assess overall coloration

29. Assessing temperature Palpating to assess skin
& moisture turgor and mobility.

30. Color Changes in the Skin
Color/Mechanism Selected Causes
Brown: Increased melanin
(greater
than a person’s genetic norm)
Blue (cyanosis):
Increased deoxyhemoglobin
from hypoxia:
● Peripheral
● Central (arterial)
● Abnormal hemoglobin
Sun exposure
Pregnancy (melasma)
Addison’s disease
Anxiety or cold environment
Heart or lung disease
Methemoglobinemia, sulfhemoglobinemia
Red: Increased visibility of
oxyhemoglobin from:
● Dilated superficial blood vessels
or increased blood flow in skin
● Decreased use of oxygen in skin
Fever, blushing, alcohol intake,
local inflammation
Cold exposure (e.g., cold ears)

31. Color/Mechanism Selected Causes
Yellow:
Increased bilirubin of jaundice
(sclera looks yellow)
Carotenemia (sclera does not
look yellow)
Pale:
Decreased melanin
Decreased visibility of
oxyhemoglobin from:
● Decreased blood flow to skin
● Decreased amount of
oxyhemoglobin
Edema (may mask skin pigments)
Liver disease, hemolysis of red
blood cells
Increased carotene intake from
yellow fruits and vegetables
Albinism, vitiligo, tinea versicolor
Syncope or shock
Anemia
Nephrotic syndrome

33. Recording the Physical Examination—The Skin
• Recording Your Findings
“Color pink. Skin warm and moist.. No suspicious
nevi, rash, petechiae, or ecchymoses.”

34. Types of Skin Lesions
MACULE
• A small, discolored spot or patch on the skin
• ULCER
• A craterlike lesion of the skin that usually extends
at least into the dermis

35. • Pustule
• A small pus filled lesion
Example: Acne
• Papule
• A solid, raised lesion that’s usually 1cm or less
in diameter

36. • Vesicles
A small fluid filled blister that usually 1cm or less
in diameter
e.g. Herpes Zoster
• Bulla
A large fluid filled blister that usually 1cm or more
in diameter
Example: Insect bite

37. • Cyst
• A closed sac in or under the skin that contain
fluid or semi solid material
• Nodule
• A raised lesion detectable by touch that usually
1cm or more in diameter

38. • Wheal
• A raised reddish area that’s commonly itchy and
least 24 hours or less
• Fissures
• A painful, crack like lesion of the skin that
extends at least into the dermis

39. A medical condition in which patches of skin
become rough and inflamed with blisters which
cause itching and bleeding
Eczema

40. Secondary Skin Lesions
• May arise from primary lesions, overtreatment,
excess scratching
• Scale—A thin flake of dead, exfoliated epidermis
• Example: Ichthyosis vulgaris
• Example: Dry skin

41. • Crust—The dried residue of skin exudates such as
serum, pus, or blood
• Example: Impetigo
• Scars—Increased connective tissue that arises
from injury or disease
• Example: Hypertrophic scar from steroid injections

42. • Lichenification:
Visible and palpable thickening of the epidermis
and roughening of the skin with increased visibility
of the normal skin furrows (often from chronic
rubbing)
• Example: Neurodermatitis
Keloids—Hypertrophic scarring that extends
beyond the borders of the initiating injury
Example: Keloid—ear lobe

43. • Erosion—Non scarring loss of the superficial
epidermis; surface is moist but does not bleed
• Example: Aphthous stomatitis, moist area after the
rupture of a vesicle, as in chickenpox
• Excoriation—Linear or punctate erosions caused by
scratching
• Example: Cat scratches

44. • Fissure—A linear crack in the skin, often resulting
from excessive dryness
• Example: Athlete’s foot
• Ulcer—A deeper loss of epidermis and dermis;
may bleed and scar
• Examples: Stasis ulcer of venous insufficiency,
syphilitic chancre

45. Vascular and Purpuric Lesions of the Skin
Cherry Angioma
• Bright or ruby red, may become purplish with
age; 1–3 mm; round, flat, sometimes raised; may
be surrounded by a pale halo
• Found on trunk or extremities
• Not significant; increase in size and number with
aging

46. • Spider Angioma
• Fiery red; very small to 2 cm; central body,
sometimes raised radiating with erythema
• Face, neck, arms, and upper trunk, but almost
never below the waist
• Seen in liver disease, pregnancy, vitamin B
deficiency; normal in some people

47. • Spider Vein
• Bluish; varies from very small to several inches;
may resemble a spider or be linear, irregular, or
cascading
• Most often on the legs, near veins; also on
anterior chest
• Often accompanies increased pressure in the
superficial veins, as in varicose veins

48. • Petechia/ Purpura
• Deep red or reddish purple; fades over time; 1–3
mm or larger; rounded, sometimes irregular, flat
• Varied distribution
• Seen if blood outside the vessels; may suggest a
bleeding disorder or, if petechiae, emboli to skin

49. • Ecchymosis
• Purple or purplish blue, fading to green, yellow,
and brown
• over time; larger than petechiae; rounded, oval, or
irregular
• Varied distribution
• Seen if blood outside the vessels; often secondary
to bruising or trauma; also seen in bleeding
disorders

50. SKIN TUMORS
• Actinic Keratoses: Superficial, flattened
papules covered by a dry scale. Often multiple;
may be round or irregular; pink, tan, or grayish.
Appear on sun exposed skin of older, fair-
skinned persons.

51. • Seborrheic Keratoses: Common, benign,
whitish-yellowish to brown, raised papules or
plaques that feel slightly greasy, velvety or warty;
have a “stuck-on” appearance. Typically multiple
and symmetrical, distributed on the trunk of older
people, also on the face and elsewhere

52. • Squamous Cell Carcinoma Usually on sun-
exposed skin of fair-skinned adults 60 years or
older. May develop in an actinic keratosis.
Usually grows more quickly than a basal cell
carcinoma, is firmer, and looks redder. The face
and the dorsum of the hand are often affected.

53. • Basal Cell Carcinoma Though malignant, grows
slowly and almost never metastasizes. Most
common in fair-skinned adults 40 years or older;
usually on the face.

54. • Kaposi’s Sarcoma in AIDS May appear in many
forms: macules, papules, plaques, or nodules
almost anywhere on the body. Lesions are often
multiple and may involve internal structures.

55. Skin Lesions
Abnormal Characteristics of a Pigmented
Lesion
DANGER SIGNS:
ABCDE
• Asymmetry
• Border irregularity
• Color variation
• Diameter
• Elevation and
Enlargement

66. NAILS
Inspect and palpate
the fingernails and toenails
Note:
● Color
● Shape
● Any lesions
Cyanosis, pallor
Clubbing
Paronychia, onycholysis
To assess capillary refill: press down on one of the
patient’s nails until it pales.
Release the nail and observe for the pink color to
return. The normal color should return in less than 3
seconds.

67. Findings in or Near the Nails
• Clubbing
• Dorsal phalanx rounded and bulbous; convexity
of nail plate increased. Angle between plate and
proximal nail fold increased to 180° or more.
Proximal nail folds feel spongy. Many causes,
including chronic hypoxia and lung cancer.

68. Paronychia
• Inflammation of proximal and lateral nail
folds, acute or chronic. Folds red, swollen,
may be tender.
• Anonychia: complete absence of nails
• Platunychia: flatting nails

69. Onycholysis
• Painless separation of nail plate from nail bed,
starting distally. Many causes.
• Terry’s Nails
• Whitish with a distal band of reddish brown.
Seen in aging and some chronic diseases.

70. Leukonychia
• White spots caused by trauma. They grow out
with nail
• Transverse White Lines
Transverse white bands appearing in the nail plate
are often caused by trauma to the more proximal
matrix in the area of the proximal nail fold;
however, some bands, such as Mees lines and
Muehrcke lines, are associated with systemic
disease

71. • Splinter hemorrhages are tiny blood clots that
tend to run vertically under the nails. In certain
conditions (in particular, infective endocarditis),
clots can migrate from the affected heart valve
and find their way into various parts of the body.

72. HAIR
Inspect and palpate the hair.
Note:
●Quantity
● Distribution
● Texture
Thin, thick
Patchy or total alopecia
Fine, coarse

73. • Alopecia Areata: Clearly demarcated round or
oval patches of hair loss, usually affecting young
adults and children. There is no visible scaling or
inflammation.

74. • Trichotillomania Hair loss from pulling, plucking,
or twisting hair. Hair shafts are broken and of
varying lengths. More common in children, often in
settings of family or psychosocial stress.

75. • Tinea Capitis (“Ringworm”) Round scaling
patches of alopecia. Hairs are broken off close to
the surface of the scalp. Usually caused by
fungal infection from Trichophyton tonsurans
from humans, microsporum canis from dogs or
cats. Mimics seborrheic dermatitis.

76. REFERENCE
• Bickly, L. S. (2017). Bates’Guide to Physical
Examination and History Taking (12th ed).
Philadelphia: J. B. Lippincott.
• Janet R. Weber & Jane H. Kelley (2013). Health
Assessment in Nursing (4th ed). : Lippincott
Williams & Wilkins