Assessment of Skin, Hair and Nails
The integumentary system, consisting of the skin, hair, and nails, is the largest organ of the body and the easiest of all systems to assess. It provides invaluable information about all other bodily systems. The skin, hair, and nails provide clues about general health, reﬂect changes in environment, and signal internal ailments stemming from other organs. Because integumentary system cells reproduce rapidly, changes in the skin, hair, and nails may be an early warning of a developing health problem. Yet, the importance of carefully assessing the integumentary system for subtle changes is often overlooked. A thorough assessment of this system may help you detect actual or potential problems, not only in the skin but also in underlying systems.
Anatomy and Physiology Review
Before you begin your assessment, you need a basic understanding of the integumentary system, including its general function and purpose. A knowledge of normal functions and structures will enable you to detect and interpret any abnormalities.
Structures and Functions of the Integumentary System. The structures of the integumentary system are the skin, hair,nails, sweat glands, and sebaceous glands. Their functions are described in the following paragraphs.
The Skin. The skin is a layer of tissue that covers all exposed body surfaces. Although similar to the mucous membranes, the skin also includes appendages such as hair follicles and sebaceous glands. Its thickness varies according to location or site.The epidermis, the outer visible layer, contains keratin, an extremely tough, protective protein substance that can cause tissue to become hard or horny. The deeper dermis is made up of proteins and mucopolysaccharides, thick, gelatinous material that provides a supporting matrix for nerve tissue, blood vessels, sweat and sebum glands, and hair follicles. Beneath the dermis lies the subcutaneous layer, made up of fatty connective tissue. Together, the layers of the skin protect underlying structures from physical trauma and ultraviolet (UV) radiation. The skin is essential to maintaining body temperature, ﬂuid balance, and sensation. It is involved in absorption and excretion, immunity, and the synthesis of vitamin D from the sun (Fig. 10.1).
The Hair. The hair is also made up of keratinized cells. Hair is found over most of the body. It grows from hair follicles supplied by blood vessels located in the dermis. Vellus, which is short, pale, and ﬁne hair, is located over all of the body. Terminal hairs, which are dark and coarse, are found on the scalp, brows, and, after puberty, on the legs, axillae, and perineum.The texture and color of hair are highly variable.Hair provides protection by covering the scalp and ﬁltering dust and debris away from the nose, ears, and eyes.
The Nails. Nails are made up of hard, keratinized cells and grow from a nail root under the cuticle. Other nail structures include the free edge,which overhangs the tip of the ﬁnger or toe; the nailbed, or epithelial layer of skin; and the lunula, the proximal part of the nail. The nailbed’s vascular supply gives the nail a pink color, although the nail itself is generally transparent. The purpose of the nails is to protect the distal portions of the digits and aid in picking up objects (Fig. 10.2).
Other Structures. Other appendages to the integument include the sweat glands and sebaceous glands. There are two types of sweat glands: eccrine glands, which are distributed over much of the body, and apocrine glands, which are limited to the genitalia, axillae, and areolae. Sebaceous glands are located near hair follicles, over most of the body. They secrete sebum, which lubricates the hair shaft.
Interaction With Other Body Systems. Changes in the integumentary system may reﬂect a problem in any of the systems described in the following paragraphs.
The Respiratory System. The respiratory system is responsible for obtaining the oxygen necessary for cellular metabolism, as well as for eliminating the carbon dioxide produced through the metabolic processes. If the process of respiration is impaired, alterations in the skin are most often evident through the development of cyanosis, a bluish discoloration, as hemoglobin becomes unsaturated with oxygen. Central cyanosis occurs when oxygen saturation is less than 80 percent and results in diffuse changes in the skin and mucous membranes.
In contrast, peripheral cyanosis, which occurs in response to decreased cardiac output, is evident in areas of the body such as the nailbeds and lips, which are cooler than other regions; it may also be evident when an individual is chilled. In severe and chronic cardiopulmonary diseases, clubbing of the nails occurs owing to hypoxia (Fig. 10.3).
The Cardiovascular System. The skin layer also contains a network of blood vessels, which contribute to its ability to regulate temperature and obtain nourishment.Alterations in the cardiovascular system can lead to circulatory impairment and changes in skin coloring and temperature, as well as to the development of lesions, ulcerations, and necrosis.When cardiac output is decreased, cyanosis may develop.
The Gastrointestinal System. The primary roles of the gastrointestinal (GI) system are the conversion of food to absorbable nutrients and the elimination of wastes. When GI disorders impair the body’s ability to excrete toxins, the accumulation of toxins may become evident in the skin. For instance, when bile excretion is impaired so that bile builds up, jaundice, a yellow discoloration, often results. When dietary lipids accumulate, xanthomas,which are lipid deposits, or papules may develop. Nutritional deficits, which may stem from GI problems, are often evident in the skin. For example, deficits in vitamin A, riboflavin, vitamin C, iron and protein may all result in skin,hair,or nail alterations.
The Urinary System. The urinary system is primarily responsible for filtering the blood, but it is also involved in the production of red blood cells and the regulation of electrolyte and fluid status.When renal function is altered and filtration decreases, toxins and ﬂuids build up in the body.The toxins often include pigmented metabolites,which alter the skin coloring. For example, an increased concentration of urea may lead to a residue of urea on the skin, which is called uremic frost. Toxins are also responsible for the development of pruritus, or itching. Calcium deposits may lead to excoriations of the skin.Altered hematologic status may be evident through ecchymoses and hematomas. Increased ﬂuid volume associated with diminishing renal function may result in edema.
The Neurological System. The skin contains an intricate system of sensory and autonomic nerve ﬁbers and serves as the body’s largest sensory organ. Not only does this network of ﬁbers permit the sensations of touch, temperature, pressure, vibration, and pain, the autonomic nervous system ﬁbers control the skin’s blood vessels and glands, regulating the skin’s temperature, moisture, and oiliness.Alterations in the nervous system can have profound effects on the skin, placing it at risk for injury or discomfort. For instance, if sensation is decreased, a person is more likely to experience trauma to the skin because he or she is less likely to detect the need to withdraw from potentially dangerous objects or activities. Irritated nerves can produce disagreeable sensations in the skin, such as burning. Alterations in the autonomic nervous system can result in drying of the skin.
The Endocrine System. Alterations of the endocrine system may affect the skin in myriad ways.Diabetes leads to alterations in skin integrity through complex processes involving changes in the immune,vascular,and neurological systems.Diabetic foot ulcers are examples of altered skin associated with diabetes. When thyroid disease occurs, the skin is often affected. In hypothyroidism, the skin is often dry and cool and becomes puffy,with nonpitting edema. It may develop a yellow hue as carotene accumulates. The hair is affected, becoming dull, brittle, and sparse. In contrast, hyperthyroidism causes the skin to be warmer, sweatier, and smoother than usual. The nails are thin and brittle and may separate from the nail plate. The hair is ﬁne and silky, with patchy hair loss. Adrenal diseases affect the skin, hair, and nails. Hypofunction of the adrenals can result in hyperpigmentation of the skin (a bronze color) and alopecia (baldness). Hyperfunction results in thin and fragile skin, petechiae, plethora, bruises, and poor wound healing.
The Lymphatic/Immune System. The immune system is involved in protecting the body from both external and endogenous factors. Impairments in the immune system are reﬂected in the skin when infectious diseases result in their typical rashes or lesions. Abnormalities of the immune system can also result in hypersensitivity and the development of atopic, or allergic, skin changes, including pruritus or rashes such as atopic dermatitis or psoriasis. Skin changes are also common in some systemic autoimmune disorders such as lupus erythematosus.
Developmental, Cultural, and Ethnic Variations
Infants. Various differences can be noted in the newborn skin. Infants have very smooth skin, partly because of their lack of exposure to the environment, but also because there is less subcutaneous tissue. Color changes can be readily seen. Newborns often appear pinker or redder because of the lack of subcutaneous tissue.Physiological jaundice may occur 2 to 3 days after birth as a result of the breakdown of excessive red blood cells at birth and immature functioning of the liver. Newborns have little or no coarse terminal hair. They shed their hair at approximately 3 months and it is soon replaced.
Eccrine sweat glands begin to function within a month after birth.The immature sweat glands lead to poor thermoregulation. With no functioning apocrine sweat glands, babies’ skin is less oily than adults’ and lacks offensive odor. The secretion of sebum by the sebaceous glands can result in cradle cap, seborrheic dermatitis, thick yellow-crusted lesions. Numerous skin lesions may also be seen on the newborn, such as mongolian spots, nevus ﬂammeus (port-wine stains), capillary hemangiomas (stork bites), hemangioma simplex (strawberry marks),milia, and erythema toxicum neonatorum.
Adolescents. Adolescence is a time of rapid hormonal change that may affect the integumentary system. During adolescence, the apocrine glands begin to enlarge and function.At this time, young people develop increased axillary sweating and the potential for a more pronounced body odor. The sebaceous glands increase sebum production and the skin becomes more oily, leading to the onset of acne. During adolescence, pubic and axillary hair and male and female body hair patterns become apparent.
Pregnant Women. During pregnancy, there is increased blood ﬂow to the skin, particularly to the hands and feet, as peripheral vessels dilate and the number of capillaries increases to dissipate heat. Along with this increased ﬂow, there is an increase in sweating and sebaceous activity. The skin thickens and separates with stretching,with the appearance of striae. Hormonal changes result in hyperpigmentation. The pigmentary changes occur on the face resulting in chloasma, on the abdominal midline (the linea alba becomes the linea nigra) and on the nipples, areolae, axillae, and vulva.
Menopausal Women. During menopause, hormonal ﬂuctuations result in hot ﬂashes, often accompanied by ﬂushing of the skin and increased pigmentation. There may be an increase in facial hair and some degree of scalp hair loss. Chloasma may occur. The incidence of skin tags increases at menopause.
Older Adults. With age, the skin atrophies. There is a decrease in production of sebum and sweat. The skin becomes drier and ﬂattens,often becoming paperlike.The elasticity decreases and wrinkles develop.There is a decreased melanocyte function, so that the hair grays and the skin becomes more pale. Target areas of increased melanocyte function result in “age spots.”There is a decrease in axillary,pubic, and scalp hair.Women may experience increased facial hair as estrogen function is lost; men experience an increase in nasal and ear hair growth. The nails grow more slowly and become thicker and more brittle.
Furthermore, speciﬁc skin lesions are more common in elderly persons, including:actinic keratoses, basal cell carcinomas, seborrheic keratoses, stasis ulcers, senile pruritus, and keratotic horns.
People of Different Cultures and Ethnic Groups. Cultural and ethnic variations can readily be seen in the integumentary system.Genetic factors determine the skin color. The greater the amount of melanin, the darker the skin color. Assessing for subtle changes in the skin becomes more of a challenge the darker the skin color. The oral mucosa is best for assessing color changes in dark-skinned people. Also, assessing the sclera for jaundice is more accurate than assessing the skin in an Asian person. Fair-skinned persons of Irish, German, or Polish descent have an increased risk for skin cancer with prolonged sun exposure. African Americans have a higher incidence of keloids, pseudofolliculitis, and mongolian spots.
Differences in hair can also be readily seen with different ethnic groups. Asians often have black, straight, silky hair,and Chinese men have very little facial hair.The hair texture of African Americans is often thick and kinky. Cultural variations may also be noted in the amount of sweat production. For example, Asians produce less sweat and therefore have less body odor. Be alert to your patient’s ethnicity when assessing the integumentary system; changes may be culturally related rather than an indication of pathology.
Performing the Integumentary Assessment
Assessment of the integumentary system includes a comprehensive health history and physical examination.The history identiﬁes any symptoms related to the integumentary system, risk factors for skin problems, and the presence of diseases in other systems that could contribute to skin problems.The physical examination identiﬁes the current condition of the integument, including any abnormal function. Throughout the assessment, be attentive to signs or symptoms of both actual and potential problems of the integument.
Health History. The health history includes obtaining biographical data and asking questions about the patient’s current health, past health, and family and psychosocial history. It also involves a review of systems. If you don’t have the time to perform a complete health history,make sure to at least perform a focused health history of the integumentary system.
Biographical Data. Brieﬂy review all biographical data. Identify your patient’s age; skin function varies by age, and certain skin diseases are more likely to develop at particular ages. For example, papules, vesicles, and pustules associated with impetigo are mostly seen in children; acne frequently occurs during puberty, and plaques and malignancies are more common in older adults. Your patient’s occupation and recreational activities can provide clues regarding the potential for exposures to harmful chemicals, trauma, or environmental hazards.Exposure to chemicals may cause a contact dermatitis. Excessive sun exposure from either work or play may increase the risk for skin cancer.Similarly, the patient’s living situation can suggest environmental exposures to factors that might be harmful to the skin.
Current Health Status. If the patient has a speciﬁc skin complaint, analyze it as you begin your history, using the PQRST system. The major complaints to be alert for include: changes in moles or other lesions,nonhealing sore or ulcer or chronic irritation, pruritus/itching, and rash, a very common complaint. Because the integumentary system also includes the hair and nails, a symptom analysis should focus on changes in these areas. Generally, the problems that trigger integumentary complaints are of a stable nature and not life-threatening, and so you will be able to proceed with the full history and physical. If the patient is overly distressed by the symptoms (e.g., severe itching or fear of malignancy), focus ﬁrst on the presenting problem and perform a comprehensive history at a later time.
Symptom Analysis. Symptom analysis tables for the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book.
Change in Mole or Lesion. Skin cancer is the most common type of cancer, and changes in a mole (nevus) or skin lesion can often evoke fear in the patient. Although there are many types of lesions, most of which are benign, it is important to be able to detect skin cancer at its earliest stages,when treatment yields the best results. There are three types of skin cancer: basal cell and squamous cell carcinomas, which affect the epidermal keratinocytes, and melanoma,which affects the melanocytes of the basal layer of the epidermis. Sun exposure is a risk factor in all types.
The majority of skin cancers are basal cell. Basal cell carcinomas are directly related to sun exposure,with 90 percent of lesions occurring on the head and neck. Basal cell carcinomas are easily treated and relatively benign. Squamous cell carcinoma is often preceded by actinic keratosis (premalignant macule or papule of rough, sandpaper texture, caused by excessive UV exposure). Sixty-six percent of these lesions occur on sun-exposed areas and respond well to treatment. Even though melanoma occurs less frequently than basal cell and squamous cell carcinomas, it is the most deadly type of skin cancer.Congenital nevi and dysplastic nevi may be precursor lesions to melanoma.
Unfortunately, there are usually no symptoms associated with skin cancers unless the lesion has metastasized regionally or distantly. In these cases, various symptoms might be present related to whether a lesion, for instance a malignant melanoma, had metastasized to another organ such as the bowel, lung, liver, or brain.
Nonhealing Sore or Chronic Ulceration. When your patient’s history includes a sore that won’t heal or a chronic ulceration, the routine symptom analysis questions will provide a good picture of the lesion and any previous self-treatment applied. Keep in mind that a nonhealing wound or chronic irritation is often associated with an underlying disease. The most common types of nonhealing wounds or chronic skin ulcerations are caused by vascular disease or pressure or by diabetes.
Pruritus. Pruritus is severe itching. It may be localized or generalized and caused by a dermatologic problem or underlying systemic problem.Pruritus is often accompanied by a rash. Itching, when not associated with a rash, may be indicative of signiﬁcant systemic disease or simply dry skin.
Itching arises from free nerve endings (nonmyelinated), which are especially abundant in the ﬂexor aspects of the wrist and ankles. It occurs as a result of a spinal reﬂex and external stimuli, such as heat, dryness, inﬂammation, and vasodilation. Psychological factors, such as depression, can inﬂuence the perception of itching,which explains the varied responses to it.A thorough symptom analysis will help you to pinpoint the underlying cause.
Rashes. Rashes, like itching, may be localized or generalized, acute or chronic, and caused by an obvious dermatologic problem or an underlying systemic problem.A thorough symptom analysis will help you to pinpoint the problem and direct your physical assessment.
Seasonal Skin Disorders. Certain skin disorders are more common during one time of year than others. Seasonal skin problems include those caused by temperature ﬂuctuations, air humidity, and exposure to contaminants. It is important to remember,however, that although these problems may be more common at certain times of the year, they may appear at any time.
Hair Changes. Hair loss (alopecia) is probably the most distressing change in hair that can occur because of its cosmetic effect.Alopecia not only refers to scalp hair but also to body hair. Normally hair growth is cyclical,with 85 to 90 percent of scalp hair in the growth phase (anagen), and the remaining 10 to 15 percent in the resting phase (telogen). Scalp hair grows about 0.25 mm/d, and about 100 strands of hair are lost per day.
Hair loss can occur for many reasons.Alopecia can be classified as scarring or cicatricial (resulting from injury such as burns, radiation, or traction with irreversible damage to the hair follicles) and nonscarring or noncicatricial (resulting from hormonal changes, medications, infectious diseases, or thyroid disease, in which the follicles remain intact with a potential to reverse the process).
Nail Changes. Changes in the nails also often reﬂect an underlying systemic problem.Changes in color and texture are frequent complaints.A symptom analysis will help you identify any underlying problems.
Past Health History. The past health history allows you to determine what illnesses or problems the patient has had in the past, including those related to the skin,hair,or nails. It additionally permits you to determine episodes of illnesses involving other systems that might have an impact on the integument.
Family History. The family history allows you to determine what, if any, integumentary problems are common to the patient’s family members.Diseases of the integument are as likely as others to have a familial predisposition. The history also helps to identify familial diseases that directly affect other systems and that might have some affect on the skin. This portion of the history also begins to explore the potential for problems stemming from the patient’s living environment.
Review of Systems. The review of systems is extremely important when exploring a complaint related to the integumentary system. It helps you identify problems in other systems that directly affect the skin, hair, and nails. Health problems directly affecting many systems can have profound effects on the integument.The review of systems is also useful in prompting the patient to identify problems that she or he previously felt were not related or worth mentioning.
Psychosocial Proﬁle. The psychosocial proﬁle serves several purposes. It provides important information regarding dietary and other habits, as well as occupational, social, and recreational activities that could inﬂuence the condition or health of the skin, hair, and nails. It provides an opportunity to explore the patient’s self-care and social activities,which may identify his or her response to an integumentary system problem.
Physical Assessment. Once you have taken the history,proceed to collect objective data through your physical examination.Even though the skin,hair,and nails are easily accessible and we look at them every day, you still need to be very objective and attentive to details that could easily be overlooked.
Approach. The techniques used in the examination of the integument are inspection and palpation.As you conduct the assessment, along with your sense of sight and touch,use your sense of smell to note any unusual odors. It is important to inspect all areas of skin, including intertriginous areas, which lie between or under folds of skin.
Throughout the examination, compare symmetrical parts. Also be aware of the “feel” of the skin, hair, and nails.You can inspect the skin in one of three ways:
1. Using a head-to-toe approach.
2. Observing all skin on the anterior, posterior, and lateral surfaces of the body.
3. Inspecting the skin by regions, as you examine the cardiovascular, respiratory, and other systems.
Regardless of your approach, a complete examination is necessary,and a systematic approach will help you avoid omissions. During the examination, keep in mind the underlying structures or organs because they may explain changes in the overlying skin. Also compare exposed with unexposed areas.Variations might be signs of “wear and tear,” poor alignment, or injury, or they may indicate the need for further history.
Performing a General Survey. A general survey of the integumentary system is typically done while obtaining the health history. Be attentive to any signs that suggest alterations in the integrity of the skin, hair, and nails. During the early observation phase, note general skin coloring, as well as any obvious variations by region.Coloring is a highly variable feature,even among people of the same race or ethnic background. Variations can indicate sun or chemical exposure, emotional responses, illness, or just a personal characteristic. Also observe the general distribution of the hair, including its condition, color, and sheen.Note the general condition of the nails. The examination also relies on your sense of smell and touch. Be attentive for any unusual odors.As you shake the patient’s hand or take vital signs, check the temperature and moisture of the skin.
In addition, consider the patient’s overall skin condition in comparison with her or his stated age. If the skin appears chronologically older, it may have been aged by chronic illness, substance use, or environmental exposures. Exposure to sunlight increases the risk of malignancy; exposure to chemicals increases the risk for various forms of dermatitis. Also do the following:
■ Determine the patient’s overall nutritional status. Signs of nutritional deﬁciencies are often evident on inspection of the skin, hair, or nails.
■ Note the patient’s apparent emotional status.This provides insight into his or her ability to cope with any real or perceived disﬁgurement associated with alterations in the integument. It may also suggest the likelihood that lesions might be self-inﬂicted.
■ Be aware of the patient’s overall body habitus—weight distribution,posture, and muscle mass.Besides providing information on nutritional status, this suggests other health problems that inﬂuence the skin. For instance, a person who has truncal obesity and a tripod posture (sitting leaning forward on elbows) may have chronic lung disease requiring systemic corticosteroid treatment. Lung disease may be reﬂected by nail clubbing and cyanosis; corticosteroid therapy may cause the skin to thin and become friable.
■ Obtain the patient’s vital signs. Elevations in temperature may indicate an infection that might be accompanied by a rash or other skin lesion.
Performing a Head-to-Toe Physical Assessment. Next, do a head-to-toe survey, checking for more speciﬁc signs of diseases affecting other organ systems that might alter the skin, hair, or nails.
Performing an Integumentary Physical Assessment. Once the general survey and head-to-toe assessment are completed, begin the focused examination of the skin, hair, and nails, using inspection and palpation. For purposes of simplicity, inspection and palpation are discussed separately below.However, rather than inspecting all areas of skin, hair, and nails, and then palpating all areas and suspicious lesions, you are more likely to inspect and palpate speciﬁc areas almost simultaneously. As you read the following information, keep in mind that areas that vary from normal should be explored using palpation.
Assessing the Skin. Use inspection and palpation to examine the skin.
Inspection. Examine the patient’s skin,noting color,odor,and the presence of lesions. Once you have determined the patient’s overall skin coloring, take a moment to decide if the coloring suggests something other than a normal variation.
Assessing Color. In addition to alterations in general coloring, it is normal for various regions of a person’s skin to differ in color,depending primarily on the amount of exposure to light. These variations are generally symmetrical. If you notice that one area—for instance, the shoulders or arms—is darker than other areas—such as the anterior chest or buttocks—make sure that the difference is symmetrical or explained. For instance, a long-distance truck driver’s left arm might be darker than the right because that arm receives greater sun exposure during daylight driving hours. (See Skin Color Variations.)
Assessing Lesions. The skin should be a continuous tissue, and so note breaks, erosions, or lesions. Document localized and/or pigmented variations, including moles, freckles, or vascular lesions, and examine them closely.
Use a ﬂashlight or penlight and a magniﬁer to determine the surface,pigmentary,or border characteristics of many lesions, particularly when they are small. Besides providing brighter light to a speciﬁc skin area, the penlight or ﬂashlight can also be used to shed tangential or oblique light to a lesion. Tangential lighting will cause the distal edge of the lesion to cast a shadow if the lesion is raised.Another use of the light is to transilluminate a lesion.For very small lesions,you will need either a small-beam penlight or a transilluminator attachment for an otoscope or ophthalmoscope. Transillumination of a raised lesion helps determine whether the lesion is solid or ﬂuid ﬁlled. Fluid-ﬁlled lesions have a yellow or pink glow,whereas solid lesions do not.
Use a transparent ruler with centimeter markings to measure any lesions you detect. Clean the ruler after each use,using the method recommended by your facility. Either the transparent ruler or a glass slide can be used as a diascope to determine whether or not a vascular lesion blanches.Press the ruler or slide gently against the lesion, noting whether it blanches or pales with the pressure.
Vascular lesions are red to purple in color. They may be caused by an extravasation of blood into the skin tissue or by visible superﬁcial vascular irregularities.
Always be attentive to the signs of malignant melanoma when assessing a skin lesion. The warning signs are easily recalled using the mnemonic “ABCD.”Any time a patient indicates that a pigmented area has newly developed or changed signiﬁcantly from its original appearance, you must be alert to the potential of malignancy. In addition to malignant melanomas, several other types of skin malignancies are less aggressive and less likely to be fatal (Figs. 10.4 and 10.5).
you detect a lesion, inspect it closely and palpate it to determine its characteristics.Decide whether it represents a primary or
secondary skin lesion. A primary lesion is one that appears in response to some
change in the internal or external environment of the skin and is not altered
by trauma.Primary lesions are categorized by whether
or not they are raised and by their overall dimensions. Different sources use
different dimensions (0.5 or
Secondary lesions result from changes in primary lesions.They either add to or take away from an existing primary lesion.
Pressure Ulcers. Pressure ulcers are a type of secondary lesion caused by unrelieved pressure.Healthy People 2010 has established a goal of reducing pressure ulcers in nursing homes by 50 percent to 8 per 1000 residents from 16 per 1000 residents reported in 1997. Assessment begins with identifying those at risk for pressure ulcer development and developing a plan to prevent pressure ulcer formation. If a pressure ulcer develops, assessment focuses on staging pressure ulcers and developing and evaluating pressure ulcer treatment plans.
Lesions may also be categorized according to their pattern, conﬁguration, and distribution.
Palpation. After inspecting the skin, explore any ﬁndings through palpation. Palpation is used to determine the skin’s temperature,moisture, texture, and turgor. It can also help to determine whether a localized lesion is raised, indented, or pedunculated and its surface characteristics.
As you palpate for temperature, you will ﬁnd that the dorsal part of your hands and your ﬁngers are most sensitive to temperature variations. Remember to wear gloves when palpating any potentially open areas of the skin.
The skin’s moisture varies among body parts, as well as with changes in the environmental temperature, physical activity,or body temperature.Perspiration is produced to cool the body. In the winter, the skin tends to be drier because of the lower ambient temperature and decreased humidity in the environment.
Turgor is assessed as an indication of elasticity. To determine turgor,pinch a fold of skin over an unexposed area, such as below the clavicle, or on the abdomen or sternum. You may also use the forearm. Do not test turgor on the dorsal hand or other areas where the skin is noticeably loose or thin. As you pinch the skinfold, it should feel resilient, move easily, and return to place quickly when released.
Assessing the Nails. Assess the nails through inspection and palpation.
Inspection. The condition of the nails often provides important clues about the patient’s overall health status. Inspect the color and shape of the nails.The color beneath the nails should be similar to the overall skin coloring, although somewhat rosier.There should be no hemorrhage. Nail texture should be uniform and not brittle. Note any grooves or lines in the nail or nailbed. Also assess for clubbing, or loss of the normal angle (Lovibond’s angle) between the nail base and the ﬁnger.When no clubbing is present, the nailbed is ﬁrm. You can further assess for clubbing by having the patient place the dorsal aspect of two opposite distal ﬁngers together, so that the nails rest against one another. In the absence of clubbing, you should be able to detect a window of light caused by the space created by Lovibond’s angle.
Palpation. Palpate the nail for texture and reﬁll.Nail texture should be uniform and not brittle. Note any grooves or lines or pitting in the nail or nailbed.To check for capillary reﬁll, press on the tip of the nail. It should blanch, and upon release the color should return within 3 seconds.
Assessing the Hair. Assessing the hair is done by inspection and palpation.
Inspection. Inspect the hair for distribution, color, and condition of the scalp.Note any increased hair growth or areas of thinning or alopecia.Also, assess the body for normal distribution of hair.The color of the hair can be very difﬁcult to assess, primarily because so many people color their hair. Inspect the scalp as you would any area of skin, assessing any lesions for size, relationship to the overall scalp plane, color, and surface integrity.A morphological description of individual lesions often provides clues to their cause. Almost any of the common skin disorders can affect the scalp. Note whether there is any adherent material on the hair. Small 1- to 2-mm white eggs are found with lice or pediculosis, which occurs on the hairs of the scalp, beard, axillae, or pubic areas.Although head lice can be seen with the naked eye, they are quite small and mobile and their eggs, called nits, are easier to see. Nits are deposited near the base of the hair shaft, so that fresh nits are usually found within 1⁄8 inch of the scalp or skin. When an infestation of lice has persisted for some time, or if nits were not removed from an earlier infestation, they will be found along a greater portion of the hair shaft because the hair will have grown during the period. Nits found 1⁄4 inch or more from the skin have probably already hatched.
Palpation. Palpate the texture of the hair. If it is unusually coarse or ﬁne, consider a thyroid disorder.
Nursing Diagnoses. Next, consider all of the data you have collected during your assessment of Mrs. Green. Use this information to identify a list of nursing diagnoses.Some possible nursing diagnoses are provided below. Cluster the supporting data.
1. Health-Seeking Behaviors, related to the fear of skin cancer
2. Risk for Impaired Skin Integrity
3. Fear, related to family history of skin cancers
Identify any additional nursing diagnoses.
■ The integumentary system provides invaluable information about your patient’s overall health status.Therefore it is important that you learn to objectively assess the skin, hair, and nails and be aware of the wide range of normal variations,which further differ according to age, race, and ethnic background.
■ During your assessment, use a consistent approach and make careful observations about the overall integrity of the tissues, as well as any speciﬁc areas of abnormality.