NCM 101 (HEALTH

ASSESSMENT)
Skin, Hair & Nail

ALPHA O. TAPEL, RN
Clinical Instructor
 Review of Anatomy and Physiology
of the Integumentary SYSTEM
 SKIN (largest organ of the body)
- protecting the body from invasion by microorganisms, chemicals, and other environmental factors;
- preventing dehydration;
- acting as a sensory organ;
- modulating body temperature and electrolyte balance;
- and synthesizing vitamin D.
• It is composed of three layers :
-Epidermal
-Dermal
-Subcutaneous tissue
o EPIDERMIS

• Outermost layer of the skin

• It is completely replaced every 3 to 4 weeks
• Functions:
-protects your body from harm against mechanical, thermal and
physical injury and hazardous substances,
-keeps your body hydrated,
- produces new skin cells and contains melanin, which determines
the color of your skin.
 o DERMIS
• Inner layer of the skin.
• It has connective tissue, blood vessels, oil and sweat glands, nerves, hair
follicles, and other structures.
• DERMAL PAPILLAE (connects the dermis to the epidermis).
• Visible in the hands and feet & create unique pattern and friction known as
FINGERPRINT.
• Functions:
- support and protect the skin and deeper layers,
- assist in thermoregulation,
- and aid in sensation.
o SUBCUTANEOUS TISSUE
• Lies beneath the dermis
• It is a loose connective tissue containing fat cells, blood vessels, nerves and
remaining portion of sweat glands and hair follicles.
• Functions:
- Insulation (to conserve internal body heat),
- thermoregulation,
- shock absorption,
- structural support (connects skin to muscles and bones),
- and energy storage (stores fat)
- Serves as cushion to protect bones and internal organs & contains vascular
pathways for the supply of nutrients & removal of waste products to & from the
skin.
 HAIR
• Consist of layers of keratinized cells, found over much of the body except or the lips,
nipples, soles of the feet, palms of the hands, labia minora and penis.
• Hair develops within a sheath of epidermal cells called the hair follicle.
• Attached to the follicle are the arrector pili muscles which contract in response to
cold and fright, decreasing surface area and causing the hair to stand erect.
• 2 General types of hair:
- Vellus( peach fuzz) short, pale, fine and present much over of the body; it provides
thermoreguation
- Terminal hair (particularly scalp and eyebrows) is longer, generally darker, and
coarser than vellus hair.
• A reduction in production of pigment results in gray or white hair.
• Hair on the head-protects the scalp, provides insulation and allows self expression.
• Nasal hair, auditory canal hair, eyelashes and eyebrows filter dust and other airborne
debris.
 NAILS
Nails are located on the distal phalanges of fingers and
toes, are hard transparent plates of keratinized
epidermal cells that grow from the cuticle.

Functions:

- to protect the fingers and toes while increasing the

precision of movements and enhancing sensation.
HEALTH ASSESSMENT
• COLLECTION OF SUBJECTIVE DATA: THE NURSING HEALTH HISTORY
 Diseases and disorders of the skin, hair and nails may be local or caused by
underlying systemic condition.
 Data’s to be collected:
- Current symptoms
- Client’s past and family history
- Lifestyle and health practices
Ask in a straightforward manner.
Nonjudgemental, sensitive approach is needed if the client has abnormalities
associated with poor hygiene or unhealthy behaviors.
Some skin disorders might be highly visible and potentially damaging to the
person’s body image and self-concept.
 HISTORY OF PRESENT
HEALTH CONCERN
• SKIN • Rationale
- Any of these symptoms may be related to
-Current skin problem: rashes, lesion, pathologic condition. Like accidents, trauma or
dryness, oiliness, drainage, bruising, abuse.
swelling or changes in skin color? What - If injuries cannot be explained or do not match to
aggravates the problem? What relieves it? what the symptoms or client’s explanation seems
unbelievable or vague physical abuse can be
suspected.

* Dry, pruritic skin, stretch marks, skin tags, dark

patches and skin infections are common in obese
clients.
- Check for birthmarks or moles. Describe
change of color, size or shape. Check signs or
characteristics of skin cancer (ABCDE).

- MULTIPLE OR ATYPICAL MOLES

INCREASE ONE’S RISK FOR SKIN
CANCER. A CHANGE IN THE
APPEARANCE O BLEEDING OF ANY
SKIN LESION, ESPECIALLY A MOLE
CAN INDICATE SKIN CANCER.

- ASYMMETRY, IRREGULAR
BORDERS, COLOR VARIATIONS,
DIAMETER GREATER THAN ¼
INCH OR 6MM AND EVOLVING OR
CHANGING OVERTIME ARE
CHARACTERISTICS OF
CANCEROUS LEIONS.
• Changes in the ability to feel pain, • Changes in sensation or temperature indicate vascular
or neurologic problems such as peripheral neuropathy
pressure, light touch or temperature related to diabetes mellitus or arterial occlusive
variations. disease. Decrease sensation increased client’s risk for
developing pressure ulcers, impaired skin integrity &
skin infections.

• Pruritus- dry skin, drug reactions, allergies, lice, tinea,

• Experiencing any pain, itching, tingling, insect bites, uremia, obstructive jaundice. –tingling,
pricking or burning referred to paresthesia.
or numbness.
-Numbness or dulling of sensations of pain temperature
& touch to the feet can be seen in diabetic peripheral
neuropathy.
• Taking medications(prescribed or over-  Some medications can cause photosensitivity reaction.
the-counter drug) using any ointments or
creams, herbal or nutritional supplements Some may exhibit allergic skin reaction(s) to specific
drugs, creams or ointments.
or vitamins. How long thus the patient
taking each of these?
• Trouble controlling body odor. Perceive • Poor hygiene practices may account for body odor,
health education is a must. Uncontrolled body odor or
oneself to have excessive perspiration. excessive or insufficient perspiration indicate an
abnormality of the sweat glands or an endocrine
problems such as hypothyroidism or hyperthyroidism.
  Patchy hair loss- infections, stress, hairstyles that put stress
Had any change in the on the hair roots, some types of chemotheraphy.

 Generalized hair loss-systemic illnesses such as

condition or appearance hypothyroidism & clients receiving
chemotherapy or radiation therapy .
certain types of

.
 Certain medications contribute to hair loss are malabsorption
syndromes, malnutrition, anorexia nervosa and bulimia.

of the nail. Describe  Also common after gastric-by-pass surgery.

 Nail changes can be seen in systemic disorders such as

malnutrition or with local irritation (ex. Nail biting)

 Bacterial infections- green, black, OR BROWN NAIL

DISCOLORATION.

 YELLOW THICK,CRUMBLING NAILS-FUNGAL

INFECTION

 WHITE COLOR AND SEPARATION OF THE NAIL PLATE

FROM THE NAIL BED-YEAST INFECTIONS.
 PERSONAL HEALTH HISTORY
• Recall having severe sunburns as a child. • Risk factor for skin cancer.

• Any recent hospitalizations or surgeries. • Hospitalization increase risk of hospital-acquired infection

such as MRSA. Major surgery or illness can cause
temporary cessation of hair and nail growth.

• Had any allergic reactions to food, medications, plants, or • Various types of allergens can precipitate a variety of skin
other environmental factors. eruptions.

• Had recent viral or bacterial illness. • Some skin rashes or lesions may be related to viruses or
bacteria.

• Some skin and hair conditions can result to hormonal

• For female clients: are you pregnant? Are your menstrual imbalance.
periods regular?
• Cutting or scratching the skin and skin breakouts and
• Any history of self-injury. rashes often have an associated psychiatric condition.
 FAMILY HISTORY
• History of recent illness, rash or other skin • Viruses (ex. chickenpox, measles) can
problems or allergy in the family. be highly contagious. Acne & atopic
dermatitis tend to be familial.
• History of skin cancer in the family.
• Genetic component is associated with
skin cancer.

• History of keloids. • Keloids are common in skin of color

(African, African-American, Asian
descent) and in persons w/ family
history of keloids.
 LIFESTYLE AND HEALTH
PRACTICES
• Do you sunbathe? What is the frequency or • Excessive or unprotected exposure to UV
duration of sun or tanning-booth exposure? use of radiation can cause premature damaging of
sunblock & what type (specify SPF) the skin & increase risk of skin cancer. Hair
can be damage as well by too much sun.
• Do you perform skin self-examination once a
month? • If the client does not knowhow to inspect the
skin, teach them how to recognize suspicious
lesions early.

• Are you regularly exposed to chemicals or • Any substance have the potential to irritate or
irritants that may harm the skin? damage the skin, hair, nails & increase one’s
risk for skin cancer.

• Older, disabled or immobile clients who spend

• Do the patient spend long period of time sitting long periods of time in one position are at risk
or lying in one position? for impaired skin integrity.
• Exposure to extreme temperature. • Extreme temperatures affect the blood supply
to the skin & can damage the skin layers.(ex.
Frosbite or burns)
• COLLECTING OBJECTIVE DATA:
PHYSICAL EXAMINATION
• Physical assessment of the skin, hair and nails provides data that may reveal local or systemic problems
or alterations in a client’s self-care related activities.
• The appearance of the skin, hair or nails also provides the nurse with data related to health maintenance
and self-care activities such as hygiene, exercise & nutrition.
• As you inspect & palpate skin, hair & nails pay special attention to lesions & growths.
o Preparing the client:
-ask the client to removed all clothing & jewelry & put on the examination gown(long examination gown or
robe)
-removed nail enamel, artificial nail, wigs, toupees or hairpieces.
-have the client sit comfortably on the examination table or bed
-to assess skin on the buttocks & dorsal surfaces of the legs, the client may lie on the side of the abdomen.
-ensure privacy by exposing the body part being examine & keep the room door closed or bed curtain
-wear gloves when palpating any lesions because you may exposed to drainage
 EQUIPMENT
• EXAMINATION LIGHT
• PENLIGHT
• MIRROR FOR CLIENT’S SELF EXAMINATION
• MAGNIFYING GLASS
• CENTIMETER RULER
• GLOVES
• WOOD LIGHT
• EXAMINATION GOWN OR DRAPE
• BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
• PRESSURE ULCER SCALE FOR HEALING (PUSH) TOOL TO
MEASURE PRESSURE ULCER HEALING
 PHYSICAL ASSESSMENT
• REMEMBER THESE KEY POINTS:

-Inspect skin color, temperature, moisture, texture

-Check skin integrity
-Be alert for skin lesions.
-Evaluate hair condition: loss or unusual growth
-Note nail bed condition & capillary refill
  VALIDATING & DOCUMENTING
FINDINGS
• Validate normal and abnormal findings w/the client, other healthcare
workers, or your instructor.
• Document both normal and abnormal findings.

 ANALYSIS OF DATA: DIAGNOSTIC REASONING

-After collecting subjective & objective data, identify abnormal findings &
clients strengths using diagnostic reasoning.
- Then, cluster the data to reveal any significant patterns or
abnormalities.
 DIAGNOSES
• HEALTH PROMOTION DIAGNOSIS
-Ex: Readiness for Health Management: Requests information on skin reactions &
effects of using a sun-tanning booth

• RISK DIAGNOSIS
-Ex: Risk for Impaired Skin Integrity related to excessive exposure to cleaning solutions
& chemicals

-Risk for imbalance body temperature related to immobility, decreased production of

natural oils & thinning skin

• ACTUAL DIAGNOSIS
-Impaired skin integrity related to immobility & decreased circulation
-Disturbed Sleep Pattern related to persistent itching of the skin
Thank You!