BY: RHODEVA JOY T.

BRAGA, RN, USRN

EXTERNAL STRUCTURES:
 Skin
 Hair
 Nails

INTERNAL STRUCTURES:
 Sebaceous
 Sweat glands
 Epidermis
 Dermis
 Subcutaneous Tissue
 The nails, located on the distal phalanges of fingers and toes,
are hard, transparent plates of keratinized epidermal cells.
 The nail body extends over the entire nailbed and has a pink
tinge as a result of the rich blood supply underneath.
 At the base of the nail is the lunula, a paler, crescent-shaped
area.
 There are two general types of hair: vellus
and terminal.
 Vellus hair is short, pale, and fine and is
present over much of the body.
 The terminal hair (particularly scalp and
eyebrows) is longer, generally darker, and
coarser than the vellus hair. Puberty
initiates the growth of additional terminal
hair in both sexes on the axillae, perineum,
and legs
 Coupled with a yearly skin exam by a doctor, self-examination of your
skin once a month is the best way to detect early warning signs of the
three main types of skin cancer: basal cell carcinoma, squamous cell
carcinoma, and melanoma. Look for a new growth or any skin change.
 What you’ll need: a bright light, a full-length mirror, a hand mirror, 2
chairs or stools, a blow dryer, body maps and a pencil.
(From The Skin Cancer Foundation. http://www.skincancer.org/step-by-step-self-examination.html)
1. Ask the client to remove all clothing and jewelry and put on an examination gown.
2. Ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as
appropriate.
3. Have the client sit comfortably on the examination table or bed for the beginning of
the examination.
4. Ensure privacy by exposing only the body part being examined.
5. Make sure that the room is a comfortable temperature.
6. Keep the room door closed or the bed curtain drawn to provide privacy as
necessary.
7. Explain what you are going to do, and answer any questions the client may have.
8. Wear gloves when palpating any lesions because you may be exposed to drainage.
 Clients from conservative religious groups (e.g., Orthodox
Jews or Muslims) may require that the nurse be the same
sex as the client. Also, to respect the client’s modesty or
desire for privacy, provide a long examination gown or robe.
 Examination light
 Penlight
 Mirror for client’s self-examination of skin
 Magnifying glass
 Centimeter ruler
 Gloves
 Wood’s light
 Examination gown or drape
 Braden Scale for Predicting Pressure Sore Risk
 Pressure Ulcer Scale for Healing (PUSH) tool to measure pressure
ulcer healing
 When preparing to examine the skin, hair, and nails,
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 and capillary refill.
Assessment Procedure Normal Findings Abnormal Findings

Inspect general skin coloration. Inspection reveals evenly Pallor (loss of color) is seen in
Keep in mind that the amount colored skin tones without arterial insufficiency,
of pigment in the skin accounts unusual or prominent decreased blood supply, and
for the intensity of color as well discolorations. Small amounts anemia. Pallid tones vary from
as hue. of melanin are common in pale to ashen without
whiter skins, while large underlying pink. Cyanosis may
amounts of melanin are cause white skin to appear
common in olive and darker blue-tinged, especially in the
skins. Carotene accounts for a perioral, nailbed, and
yellow cast. conjunctival areas. Dark skin
may appear blue, dull and
lifeless in the same areas.
The older client’s skin becomes pale due to
decreased melanin production and decreased
dermal vascularity
 Skin color ranges from pale white with pink, yellow, brown, or olive
tones to dark brown or black.
 No strong odor should be evident, and the skin should be lesion free.
 Skin should be soft, warm, slightly moist with good turgor and without
edema or lesions.
 Dark-skinned newborns have lighter skin color than their parents.
Their color darkens with age. Bluish pigmented areas called
Mongolian spots may be noted on the sacral areas of Asian, black,
Native American, and Mexican-American infants.
 Abnormal Findings

Central cyanosis results from a cardiopulmonary problem

whereas peripheral cyanosis may be a local problem resulting
from vasoconstriction. To differentiate between central and
peripheral cyanosis, look for central cyanosis in the oral mucosa.
Jaundice in light- and dark-skinned people is characterized by
yellow skin tones, from pale to pumpkin, particularly in the sclera,
oral mucosa, palms, and soles. Acanthosis nigricans is
roughening and darkening of skin in localized areas, especially
the posterior neck (Stuart et al., 1999).
 Yellow skin may indicate jaundice or passage of
meconium in utero secondary to fetal distress.
 Jaundice within 24 hours after birth is pathologic and
may indicate hemolytic disease of the newborn.
 Blue skin suggests cyanosis, pallor suggests anemia,
and redness suggests fever, irritation.
 Assessment Normal Findings Abnormal Findings
Procedure
While inspecting Client has slight or no odor of perspiration, A strong odor of perspiration or foul
skin coloration, depending on activity. odor may indicate disorder of sweat
note any odors glands. Poor hygiene practices may
emanating from indicate a need for client teaching
the skin. or assistance with activities of daily
living.
Inspect for color Keep in mind that some clients have suntanned Rashes, such as the reddish (in
variations. Inspect areas, freckles, or white patches known as vitiligo. light-skinned people) or darkened
localized parts of The variations are due to different amounts of (in dark-skinned people) butterfly
the body, noting melanin in certain areas. A generalized loss of rash across the bridge of the nose
any color variation. pigmentation is seen in albinism. Dark-skinned and cheeks, characteristic of
clients have lighter-colored palms, soles, nailbeds, discoid lupus erythematosus (DLE).
and lips. Frecklelike or dark streaks of pigmentation Albinism is a generalized loss of
are also common in the sclera and nailbeds of dark- pigmentation. Erythema (skin
skinned clients. redness and warmth) is seen in
inflammation, allergic reactions, or
trauma.
 Many skin assessment findings are considered normal
variations in that they are not health- or life-threatening. For
example, freckles are common variations in fair-skinned
clients, whereas unspotted skin is considered the ideal.
Scars and vitiligo, on the other hand, are not exactly normal
findings because scars suggest a healed injury or surgical
intervention and vitiligo may be related to a dysfunction of the
immune system. However, they are common and usually
insignificant. Other common findings appear below.
Ecchymoses in various stages or in
unusual locations or circular burn areas
suggest child abuse although bruising or
burning may also be from cultural practices
such as cupping or coining. Petechiae,
lesions, or rashes may indicate serious
disorders.
Ecchymosis Petechiae
 NORMAL FINDINGS ANBNORMAL FINDINGS

White-skinned clients have darker Erythema in the dark-skinned client

pigment around nipples, lips, and may be difficult to see. However,
genitalia. the affected skin feels swollen and
warmer than the surrounding skin.
 Assessment Normal Findings Abnormal Findings
Procedure
While inspecting Client has slight or no odor of perspiration, A strong odor of perspiration or foul
skin coloration, depending on activity. odor may indicate disorder of sweat
note any odors glands. Poor hygiene practices may
emanating from indicate a need for client teaching
the skin. or assistance with activities of daily
living.
Inspect for color Keep in mind that some clients have suntanned Rashes, such as the reddish (in
variations. Inspect areas, freckles, or white patches known as vitiligo. light-skinned people) or darkened
localized parts of The variations are due to different amounts of (in dark-skinned people) butterfly
the body, noting melanin in certain areas. A generalized loss of rash across the bridge of the nose
any color variation. pigmentation is seen in albinism. Dark-skinned and cheeks, characteristic of
clients have lighter-colored palms, soles, nailbeds, discoid lupus erythematosus (DLE).
and lips. Frecklelike or dark streaks of pigmentation Albinism is a generalized loss of
are also common in the sclera and nailbeds of dark- pigmentation. Erythema (skin
skinned clients. redness and warmth) is seen in
inflammation, allergic reactions, or
trauma.
 Assessment Procedure Normal Findings Abnormal Findings
Check skin integrity, especially Skin is intact, and there are no Skin breakdown is initially noted
carefully in pressure point areas. reddened areas. as a reddened area on the skin
Use the Braden Scale to predict that may progress to serious
pressure sore risk. If any skin and painful pressure ulcers.
breakdown is noted, use the Depending on the color of the
PUSH tool to document the client’s skin, reddened areas
degree of skin breakdown. may not be prominent, although
the skin may feel warmer in the
Clinical Tip: In the obese client, area of breakdown than
carefully inspect skin on the elsewhere.
limbs, under breasts, and in the
groin area where problems are
frequent.
 During any skin assessment, the nurse remains watchful for
signs of skin breakdown, especially in cases of limited
mobility or fragile skin (e.g., in elderly or bedridden clients).
Pressure ulcers, which lead to complications such as
infection, are easier to prevent than to treat. Some risk
factors for skin breakdown leading to pressure ulcers include
poor circulation, poor hygiene, infrequent position changes,
dermatitis, infection, or traumatic wounds.
 Assessment Procedure Normal Findings Abnormal Findings
Inspect for lesions. Observe the Smooth, without lesions. Lesions may indicate local or
skin surface to detect Stretch marks (striae), healed systemic problems. Primary
abnormalities. Note color, shape, scars, freckles, moles, or lesions arise from normal skin
and size of lesion. For very small birthmarks are common due to irritation or disease.
lesions, use a magnifying glass findings. Secondary lesions from
to note these characteristics. changes in primary lesions.
Vascular lesions, reddish-bluish
lesions, are seen with bleeding,
venous pressure, aging, liver
disease, or pregnancy. Skin
cancer lesions can be either
primary or secondary lesions
and are classified as squamous
cell carcinoma, basal cell
carcinoma, or malignant
melanoma.
Primary skin lesions are original lesions arising
from previously normal skin. Secondary lesions
can originate from primary lesions.
Secondary skin lesions result from
changes in primary lesions.
 Vascular skin lesions are associated with bleeding,
aging, circulatory conditions, diabetes, pregnancy and
hepatic disease among other problems.
 Malignant melanoma is usually evaluated according to the mnemonic
ABCDE:
 A for asymmetrical
 B for borders that are irregular (uneven or notched)
 C for color variations
 D for diameter exceeding 1 ⁄8 to 1 ⁄4 of an inch
 E for elevated, not flat. Danger signs of malignant melanoma include
any of the above factors. However, smaller areas may indicate early
stage melanomas. Other warning signs include itching, tenderness, or
pain, and a change in size or bleeding of a mole. New pigmentations
are also warning signs. (American Cancer Society; American Academy
of Dermatology.)
When examining female or obese clients, lift
the breasts (or ask the client to lift them) and
skin folds to inspect all areas for lesions.
Perspiration and friction often cause skin
problems in these areas in obese clients
(Brown et al., 2004).
NORMAL: Older clients may have skin lesions
because of aging. Some examples are
seborrheic or senile keratoses, senile
lentigines, cherry angiomas, purpura, and
cutaneous tags and horns.
 Assessment Procedure Normal Findings Abnormal Findings

If you suspect a fungus, shine a Wood’s Lesion does not Blue-green fluorescence indicates fungal
light (an ultraviolet light filtered through a fluoresce. infection.
special glass) on the lesion.

If you observe a lesion, note its location, Normal lesions may In abnormal findings, distribution may be
distribution, and configuration. Measure be moles, freckles, diffuse (scattered all over), localized to
the lesion with a centimeter ruler. birthmarks, and the one area, or in sun-exposed areas.
like. They may be Configuration may be discrete (separate
scattered over the and distinct), grouped (clustered),
skin in no particular confluent (merged), linear (in a line),
pattern. annular and arciform (circular or arcing),
or zosteriform (linear along a nerve
route).
 Vitiligolesions better
evidenced under Wood's
lamp than under visible
light
 Assessment Procedure Normal Findings Abnormal Findings
Palpate skin to assess texture. Skin is smooth and Rough, flaky, dry skin is
Use the palmar surface of even. seen in hypothyroidism.
your three middle fingers to Obese clients often report
palpate skin texture. dry, itchy skin.

Palpate to assess thickness. If Skin is normally thin Very thin skin may be
lesions are noted when but calluses (rough, seen in clients with
assessing skin thickness, put thick sections of arterial insufficiency or in
gloves on and palpate the epidermis) are those on steroid therapy.
lesion between the thumb and common on areas of
finger. Observe for drainage or the body that are
other characteristics. exposed to constant
pressure.
 Assessment Procedure Normal Findings Abnormal Findings

Palpate to assess Skin surfaces vary from Increased moisture or

moisture. Check under moist to dry depending diaphoresis (profuse
skin folds and in on the area assessed. sweating) may occur in
unexposed areas. Recent activity or a warm conditions such as fever
environment may cause or hyperthyroidism.
increased moisture. Decreased moisture
occurs with dehydration
or hypothyroidism.
Clammy skin is typical in
shock or hypotension.
Some nurses believe that using the dorsal
surfaces of the hands to assess moisture
leads to a more accurate result.
The older client’s skin may feel dryer than
a younger client’s skin because sebum
production decreases with age.
 Assessment Procedure Normal Findings Abnormal Findings
Palpate to assess temperature. Skin is normally a warm Cold skin may accompany shock
Use the dorsal surfaces of your temperature. or hypotension. Cool skin may
hands to palpate the skin. accompany arterial disease. Very
warm skin may indicate a febrile
state or hyperthyroidism.
Palpate to assess mobility and Skin pinches easily and Decreased mobility is seen with
turgor. Ask the client to lie down. immediately returns to its original edema. Decreased turgor (a slow
Using two fingers, gently pinch position. return of the skin to its normal
the skin on the sternum or under state taking longer than 30
the clavicle. Mobility refers to how seconds) is seen in dehydration.
easily the skin can be pinched.
Turgor refers to the skin’s
elasticity and how quickly the skin
returns to its original shape after
being pinched.
You may also want to palpate with the
palmar surfaces of your hands because
current research indicates that these
surfaces of the hands and fingers may be
more sensitive to temperature (Cantwell-
Gab, 1996).
The older client’s skin loses its turgor
because of a decrease in elasticity and
collagen fibers. Sagging or wrinkled skin
appears in the facial, breast, and scrotal
areas.
Skin is warm and slightly moist. Vernix
caseosa (cheesy, white substance that is
found on the skin, especially in skin folds)
is a common finding; it eventually absorbs
into the skin.
 Assessment Procedure Normal Findings Abnormal Findings

Palpate to detect edema. Skin rebounds and does Indentations on the skin
Use your thumbs to not remain indented may vary from slight to
press down on the skin when pressure is great and may be in one
of the feet or ankles to released. area or all over the body.
check for edema
(swelling related to
accumulation of fluid in
the tissue).
 Assessment Normal Findings Abnormal Findings
Procedure
Have the client remove Natural hair color, as opposed to Nutritional deficiencies may cause patchy
any hair clips, hair pins, chemically colored hair, varies gray hair in some clients. Severe
or wigs. Then inspect the among clients from pale blond to malnutrition in African-American children
scalp and hair for general black to gray or white. The color is may cause a copper-red hair color (Andrews
color and condition. determined by the amount of & Boyle, 1999).
melanin present.
African-American children usually have
hair that is curlier and coarser than white
children.
Tufts of hair over spine may indicate spina
bifida occulta.
 Assessment Normal Findings Abnormal Findings
Procedure
At 1-inch intervals, Scalp is clean and dry. Excessive scaliness may indicate
separate the hair from the Sparse dandruff may be dermatitis. Raised lesions may indicate
scalp and inspect and visible. Hair is smooth and infections or tumor growth. Dull, dry hair
palpate the hair and scalp firm, somewhat elastic. may be seen with hypothyroidism and
for cleanliness, dryness However, as people age, malnutrition. Poor hygiene may indicate
or oiliness, parasites, and hair feels coarser and a need for client teaching or assistance
lesions. Wear gloves if drier. with activities of daily living. Pustules
lesions are suspected or with hair loss in patches are seen in
if hygiene is poor tinea capitis, a contagious fungal
disease. Infections of the hair follicle
(folliculitis) appear as pustules
surrounded by erythema.
 Individuals of black African descent often have very dry
scalps and dry, fragile hair, which the client may condition
with oil or a petroleum jelly-like product. (This kind of hair is
of genetic origin and not related to thyroid disorders or
nutrition. Such hair needs to be handled very gently.)
 Assessment Normal Findings Abnormal Findings
Procedure
Inspect amount Varying amounts of Excessive generalized hair loss may occur with
and distribution of terminal hair cover the infection, nutritional deficiencies, hormonal
scalp, body, scalp, axillary, body, disorders, thyroid or liver disease, drug toxicity,
axillae, and pubic and pubic areas hepatic or renal failure (Sabbagh, 1999). It may
hair. Look for according to normal also result from chemotherapy or radiation
unusual growth gender distribution. therapy. Patchy hair loss may result from
elsewhere on the Fine vellus hair covers infections of the scalp, discoid or systemic lupus
body. the entire body except erythematosus, and some types of
for the soles, palms, chemotherapy.
lips, and nipples. Hirsutism (facial hair on females) is a
Normal male pattern characteristic of Cushing’s disease and results
balding is symmetric. from an imbalance of adrenal hormones or it
may be a side effect of steroids.
Older clients have thinner hair because of a
decrease in hair follicles. Pubic, axillary, and
body hair also decrease with aging. Alopecia is
seen, especially in men. Hair loss occurs from
the periphery of the scalp and moves to the
center. Elderly women may have terminal hair
growth on the chin owing to hormonal changes.
 Assessment Normal Findings Abnormal Findings
Procedure
Inspect nail Nails are clean Dirty, broken, or jagged fingernails may
grooming and and manicured. be seen with poor hygiene. They may
cleanliness. also result from the client’s hobby or
occupation.
Inspect nail Pink tones should Pale or cyanotic nails may indicate
color and be seen. Some hypoxia or anemia. Splinter
markings. longitudinal ridging hemorrhages may be caused by
is normal. trauma. Beau’s lines occur after acute
illness and eventually grow out. Yellow
discoloration may be seen in fungal
infections or psoriasis. Nail pitting is
also common in psoriasis
Dark-skinned children have deeper nail
pigment. Nails extend to end of fingers or
beyond; are well-formed.
Blue nailbeds indicate cyanosis. Yellow
nailbeds indicate jaundice. Blue-black
nailbeds suggest a nailbed hemorrhage.
Dark-skinned clients may have
freckles or pigmented streaks in
their nails.
 Assessment Normal Findings Abnormal Findings
Procedure
Inspect shape There is normally a Early clubbing (180-degree angle with
of nails. 160-degree angle spongy sensation) and late clubbing
between the nail (greater than 180-degree angle) can
base and the skin. occur from hypoxia. Spoon nails
(concave) may be present with iron
deficiency anemia
Assessment Procedure Normal Findings Abnormal Findings

Palpate nail to Nails are hard and Thickened nails (especially

assess texture. basically immobile. toenails) may be caused by
decreased circulation.
Palpate to assess Nails are smooth and Paronychia (inflammation)
texture and firm; nailplate should indicates local infection.
consistency, noting be firmly attached to Detachment of nailplate from
whether nailplate is nailbed. nailbed (onycholysis) is seen
attached to nailbed. in infections or trauma.
 Assessment Normal Findings Abnormal Findings
Procedure
Test capillary Pink tone returns There is slow (greater than 2 seconds)
refill in nailbeds immediately to capillary nailbed refill (return of pink
by pressing the blanched nailbeds tone) with respiratory or cardiovascular
nail tip briefly when pressure is diseases that cause hypoxia.
and watching released.
for color
change