Adult Assessment: Hair, Skin and Nails

• Key Points When Preparing to Examine the Skin

  1. Inspect color

  2. Temperature

  3. Moisture

  4. Texture

  5. Integrity

  6. Lesions
• Integumentary System


  Consists of the skin, hair, and nails
• Assessment of the Skin

  Involves inspection and palpation, in some instances, the nurse may also use the olfactory sense to detect unusual skin odors; these are usually most evident in the skinfolds or in the axillae, pungent body odor is frequently related to poor hygiene, hyperhidrosis (excessive perspiration), or bromhidrosis (foul-smelling perspiration)
• Function of the Skin

  • 1. Protection
  • 2. Thermoregulation
  • 3. Vitamin D Synthesis
  • 4. Excretion and Absorption
  • 5. Cutaneous sensation
• Subjective Data Collection

  Ask for any history of skin cancer or current skin problems like allergies etc., use COLDSPA to explore health concerns
• The integumentary system provides clues about general health, reflects changes in the environment, and signals internal ailments stemming from other organs
• Anatomy of the Skin

  • EPIDERMIS: Outer layer of skin with four layers including Stratum corneum, Stratum lucidum, Stratum Granulosum, and Stratum Germinatum (Basale) containing Melanocyte/Melanin
  • DERMIS: Made up of proteins and mucopolysaccharides, well-vascularized, contains collagen, elastic fibers, nerve endings, lymph vessels, origin of sebaceous and sweat glands and hair follicles
  • HYPODERMIS (SUBCUTANEOUS): Loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portion of sweat glands and hair follicles, stores fat as an energy reserve and provides insulation to conserve internal body heat, serves as a cushion to protect bones and internal organs
• Erythema is redness of the skin
• Cyanosis

  Bluish-black color of the skin
• Acanthosis Nigricans


  Associated with diabetes
• Central Cyanosis

  A generalized bluish discoloration of the body and the visible mucous membranes
• Physical Assessment Proper

  Skin color assessment
• Skin color variations

  • Hyperpigmentation
  • Hypopigmentation
  • Vitiligo
  • Albinism
• Normal findings in skin color inspection

  • Varies from light to deep brown, from ruddy pink to light pink
  • Pallor
  • Cyanosis
  • Jaundice
  • Erythema
  • Acanthosis Nigricans
• PUSH (Pressure Ulcer Scale for Healing) Tool is used to document the degree of skin breakdown
• Grading scale for pressure sores

  • Stage 1: Nonblanchable erythema of intact skin
  • Stage 2: Partial thickness loss involving both epidermis and dermis
  • Stage 3: Full-thickness loss involving subcutaneous tissue
  • Stage 4: Full-thickness loss with extensive involvement of muscle, bone, or supporting structures
• Peripheral Cyanosis

  Bluish discoloration of the distal extremities (Hands, fingertips, toes)
• Erythema


  Redness of the skin
• Jaundice or Icterus


  Yellowish color of the skin
• Technique and normal findings for skin color inspection

  Inspect all body areas starting from the crown of the head, progressing caudally to the feet, noting general skin color and any pigment changes
• Causes of pungent body odor

  • Poor hygiene
  • Hyperhidrosis (excessive perspiration)
  • Bromhidrosis (foul-smelling perspiration)
• Pallor


  Loss of color
• Types of exudate

  • Serous exudate: Clear, thin, and watery fluid
  • Serosanguineous exudate: Thin and watery with light red or pink hue
  • Sanguineous exudate: Bright red, fresh blood
  • Purulent exudate: Thick, opaque, and odorous build-up from infection
• Braden Scale is used to predict pressure sore risk
• Lesion Distribution Patterns

  • Asymmetric: Distributed solely on one side of the body
  • Confluent: Enlargement or multiplication, begin to coalesce to form larger lesion
  • Diffuse: Distributed widely across affected area without any pattern
  • Discrete: Single, separated, well-defined borders
  • Generalized: Distributed over a large body area
  • Grouped: Clustered
  • Localized: Located at a distinct area
  • Satellite: Single lesion(s) in close proximity to a larger lesion
  • Symmetric: Distributed equally on both sides of the body
  • Zosteriform: Distributed along dermatome
• Braden Scale includes sensory reception, moisture, activity, mobility, nutrition, friction and shear assessments
• Skin Lesions assessment


  Inspect, palpate, and describe skin lesions according to location, distribution, color, configuration, size, shape, type, or structure
• Primary Morphology

  • Flat (nonpalpable)
  • Elevated (palpable)
• Vascular Lesions

  • Scale: Flaking of the skin surface
  • Purpura: Skin bleeding
• Lesion Configurations

  • Annular: Ring-like, circular
  • Arciform: Half-ring
  • Linear: Line-shaped
  • Polymorphous: Several different shapes
  • Punctuate: Small, marked with points or dots
  • Serpiginous: Curving, snake-like
  • Nummular/Discoic: Coin-shaped
  • Umbilicated: Central depression
  • Filiform: Papilla-like or finger-like projections
  • Verruciform: Circumscribed, papular with rough surface
• Push Tool is used for adult assessment of skin, hair, and nails
• Types of exudate

  • Serosanguineous: Thin and watery with light red or pink hue
  • Sanguineous: Bright red, fresh blood (may be hemorrhagic)
  • Purulent: Thick, opaque, and odorous build-up from infection
• Types of Skin Lesions

  • Primary Lesion: Initial alteration in the skin directly associated with a disease process
  • Secondary Lesion: Arises from a change in a primary lesion, maybe initiated by external forces or the healing process
• Crust


  Dried exudates, dried serum, blood, or pus on the surface of the skin
• Mr. Francis Vincent Acena is the subject of the adult assessment on skin, hair, and nails
• Scar


  Skin mark left after healing of wound or lesion
• Skin lesions

  • Pustule
  • Vesicle
  • Bulla
  • <0.5cm
  • >0.5cm
  • Nodule
  • Tumor
  • <2cm
  • >2cm
  • Petechiae
  • Purpura
  • Hematoma
  • Ecchymosis
• Palpate skin to assess texture using the palmar surface of your middle fingers
• Normal skin consistency is smooth and even
• Erosion


  Loss of superficial epidermis that does not extend to the dermis