skin ,hair, and nails assessment

• Skin, Hair, and Nail


  External structures that serve a variety of functions
• Skin, Hair, and Nail

  • Sebaceous and sweat glands originate within skin and have many vital functions
• Melanin


  The major determinant of skin color
• Other determinants of skin color

  Capillary blood flow, chromophores (carotene and lycopene), and collagen
• Function of Skin, Hair, Nails

  • PROTECTION
• Hair follicle


  Sheath of epidermal cells where hair develops
• Hair growth


  Occurs at the base of the follicle where cells of the hair bulb are nourished
• Collecting subjective data


  1. History of current health problem

  2. Past and family histories

  3. Lifestyle and health practices
• Past history


  • Describe any previous problems with skin, hair, or nails, treatment or surgery and its effectiveness
  • Have you ever had any allergic skin reactions to food, medications, plants, or other environmental substances?
  • Have you had a fever, nausea, vomiting, gastrointestinal (GI), or respiratory problems?
  • For female clients: Are you pregnant? Are your menstrual periods regular?
• Family history


  • Has anyone in your family had a recent illness, rash, or other skin problem or allergy? Describe
  • Has anyone in your family had skin cancer?
• Lifestyle and practices


  • Do you sunbathe? What type of protection do you use?
  • In your daily activities, are you regularly exposed to chemicals that may harm the skin (e.g.. paint, bleach, cleaning products. weed killers, insect repellents. petroleum)
  • Do you spend long periods of time sitting or lying in one position?
  • Have you had any exposure to extreme temperatures?
  • What kinds of foods do you consume in a typical day? How much fluid do you drink each day?
  • What is your daily routine for skin, hair, and nail care?
  • What products do you use (e.g.. soaps. lotions, oils, cosmetics, self-tanning products. razor type, hair spray, shampoo. coloring, nail enamel)? How do you cut your nails?
• Collecting objective data


  1. Interview approach (COLDSPA) for Nursing Assessment

  2. Physical Examination
• Equipment and Supplies


  • Examination light and penlight
  • Mirror for client's self exam of skin
  • Magnifying glass, Wood's light
  • Centimeter ruler
  • Gloves and examination gown
• Physical Examination strategy


  1. INSPECTION

  2. PALPATION
• Key assessment points


  • Skin color, temperature, moisture, texture, integrity, lesions
  • Hair condition, loss, or unusual growth
  • Nail bed condition and capillary refill

  
• Inspect skin


  1. General skin coloration

  2. Color variations

  3. Integrity

  4. Lesions

  
• Common skin variations (non-life-threatening)

  • Freckles
  • Vitiligo
  • Striae
  • Seborrhic keratosis warty pigmented lesions
  • Scar
  • Mole
  • Cutaneous tags
  • Cutaneous horns
  • Cherry angiomas
• Macule


  < 1 cm, circumscribed border, flat, nonpalpable skin color change
• Patch


  > 1 cm, may have irregular border, flat, nonpalpable skin color change
• Papule


  < 0.5 cm, elevated, palpable solid mass, superficial, circumscribed border
• Plaque


  > 0.5 cm, elevated, palpable solid mass, superficial, circumscribed border
• Wheal


  Elevated mass with transient borders, often irregular, size and color varies, caused by movement of serous fluid into the dermis, palpable lesions with fluid
• Cyst


  Encapsulated fluid-filled or semisolid mass in the subcutaneous tissue or dermis
• Nodule


  0.5 – 2cm, elevated, palpable, solid mass, extends deeper into the dermis than a papule, circumscribed
• Tumor


  > 1-2 cm, elevated, palpable, solid mass, extends deeper into the dermis than a papule, does not always have sharp borders
• Vesicle


  < 0.5 cm, circumscribed, elevated, palpable mass containing serous fluid
• Bulla


  > 0.5 cm, circumscribed, elevated, palpable mass containing serous fluid
• Pustule


  Pus-filled vesicle or bulla
• Palpate skin


  1. Texture, thickness

  2. Temperature, moisture

  3. Mobility, turgor

  4. Lesions

  
• Inspect scalp and hair

  1. Condition, cleanliness, texture

  2. Amount, distribution

  3. Dryness, oiliness

  4. Parasites, lesions
• Inspect nails


  1. Grooming, cleanliness, consistency

  2. Color, markings, shape, texture

  3. Nail plate attachment to nailbed

  4. Capillary refill
• Nail disorders


  • Beau's lines (Acute illness)
  • Spoon nails (Iron deficiency anemia)
  • Early clubbing (Hypoxia)
  • Late clubbing (Hypoxia)
  • Pitting (Psoriasis)
  • Parohychia (local infection)
• Nail shape


  160 degree angle between nail base and the skin

  
• Nail clubbing


  • Early clubbing (Hypoxia)
  • Late clubbing (Hypoxia)
• Paronychia


  Local infection
• Skin, Hair, and Nail assessment

  • Inspect shape of nails
  • 160 degree angle between nail base and the skin
  • Palpate nail to assess texture and consistency and noting whether nail plate is attached to nail bed
  • Hard and immobile
  • Testing capillary refill

  
• Skin, Hair, and Nail assessment

  1. Inspect

  2. Palpate

  3. Test
• Wellness nursing diagnosis


  Health-seeking behavior
• Validation and Documentation of Findings

  1. Subjective data

  2. Objective data
• Risk nursing diagnosis


  Risk for impaired skin integrity related to excessive exposure to cleaning solutions and chemicals