05. Assessment of Skin, Hair and Nails


Nursing Faculty



Theme 1: Assessment of Skin, Hair and Nails

Aim: To be able to perform health assessment of skin, hair and nails of the patient and find out the disorders.

Professional orientation of students: Think of the skin as the body’s largest organ system- it covers 20 square feet of surface area in the average adult. The skin is the sentry that guards the body from environmental stresses (e.g. trauma, pathogens, dirt) and adapts it to other environmental influences (e.g. heat, cold) 

Methodology of Practical Class. (9.00-12.00)

Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):

During examination of the patient students have to use such communicative algorithm:

Complaints and anamnesis taking in patients

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Take complaints and anamnesis in a patient.

5. Explain to the patient results of his/her lab tests correctly and accessibly.

6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.

7. Conversation accomplishment.

Objective examination:

Physical methods of examination of patients with internal diseases

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a patient, what examinations will be carried out and get his/her informed consent.

5. Find a contact with the patient and make an attempt to gain his/her trust.

6. Inform about the possibility of appearing of unpleasant feelings during the examination.

7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).

8. Examination (demonstration of clinical skill).

9. Explain to the patient results of his/her lab tests correctly and accessibly.

10. Conversation accomplishment.

Estimation of laboratory and instrumental investigations

Informing about the results of examination of patients with internal diseases

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a patient results of his/her lab tests correctly and clearly.

5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).

Planning and prognosis the results of the conservative treatment

Friendly facial expression and smile.

1. Gentle tone of speech.

2. Greeting and introducing.

3. Correct and clear explanation of necessary treatment directions.

4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.

5. Conversation accomplishment.

Work 1. Work in groups. To perform the assessment of skin, hair and nails of the patient.

Skin Assessment



  • Albinism

  • Vitiligo

  • Jaundice

  • Carotenemia

  • Pallor

  • Cyanosis

  • Erythema

  • Melanin

Vascular Lesions

  • Ecchymosis

  • Petechiae

  • Spider Angiomas

  • Telangiectasia

  • Venous Star

  • Cherry Angioma





Skin Lesions

  • Color

  • Type

  • Pattern, grouping, or arrangements

  • Location

  • Size

  • Mobility/Consistency

Inspection of Nails

·         Color

·         Consistency

·         Smoothness

    • Ridges/Cracks/Pitting/Depressions

·         Length/Shape

·         Cleanliness

Normal Nail

·         Flat and slightly curved

·         Smooth

·         Uniform thickness

·         Pigment bands in a dark-skinned person

·         Firm nail base that adheres to nail bed

·         Color-depends on skin color

Inspection of Nails-Thickness

Thickening of nails (Hypertrophy)

    • repeated trauma

    • fungal nail infection

    • decreased vascular circulation

Thinning of nails (Brittleness)

    • inadequate nutrition

    • poor peripheral circulation

    • pregnancy (no prenatal vitamins)

Inspection of Nails-Smoothness

Pitting of Nail

    • psoriasis

Beau’s Lines--transverse depressions

    • severe acute illness

    • malnutrition

    • anemia

Inspection of Nails

Nail Clubbing

    • Normal angle is 160 degrees

    • Clubbing present when angle is 180 degrees

Capillary Refill

    • less than 3 seconds

Nail Color

Exogenous Color Changes

·Silver Nitrate

Gentian Violet

Endogenous Color Changes

Leukonychia (white spots or streaks)

Yellow Nails

    • lymphatic abnormalities

    • thyrotoxicosis

    • nicotine staining

Green Nails

    • pseudomonas infection

Color Changes cont.

·Blue Nails

    • vascular disease

    • cyanosis

Bright Pink Nails

    • GI disease

    • nutritional disorders

Vertical Brown Lines

    • renal disease

Miscellaneous Nail Changes


    • chronic eczema

    • systemic disease

    • anemia


    • heart disease

    • psoriasis

    • fungal infections

Misc. Nail Changes cont.


    • monilia

    • diabetes

    • bacterial infections

    • syphilis

    • leprosy

Splinter Hemorrhages

    • subacute bacterial endocarditis

Seminar discussion of theoretical issues. (12.00-14.00)

Individual Students Program.

Test evaluation and situational tasks. (14.15.-15.00)

1. The client tells the nurse that his skin is darker now than a week ago. Which condition could be responsible for this change?


Exposure to heat


Exposure to cold


Exposure to excess moisture


Exposure to ultraviolet light



2. What is the most important data for the nurse to obtain from a client who has a persistent rash on both hands?






Occupation and hobbies


Socioeconomic status



3. The client, who caught the thumb in a drawer, has a collection of blood at the base of the nail and asks you when this discoloration will be gone. What is your best answer?


“Discoloration that occurs under the nail is permanent.”


“Exposing the area to sunlight will cause the discoloration to fade.”


“The blood will be reabsorbed in about 2 weeks, just like any other bruise.”


“The blood will be gone when the nail completely grows beyond the injury in 3 to 4 months.”



4. You observe yellow-tinged sclera on a client with dark skin. Based on this observation, what is your best action?


Examine the soles of the client's feet.


Nothing; this is a normal finding on all people with dark skin.


Inspect the client's oral mucosa and hard palate for other indications of jaundice.


Notify the physician of the possibility that the client has hepatitis or another liver disorder.



5. You observe clubbing of the fingers in an older man. What is your interpretation of the significance of this finding?


You should ask the client if this condition has been present since birth.


This finding is most commonly associated with chronic disorders of impaired gas exchange.


You should ask the client about his occupation and hobbies and any other activities involving exposure of the hands to harsh chemicals.


Clubbing of the fingers is a common age-related change and is considered a normal finding among older adults, especially men.



6. What problem are you alerted to in a client who has chronically inflamed soft tissue folds around the nail plates on all fingers?


Probable fungal infection


Long-term use of nail polish


Poorly controlled diabetes mellitus


Frequent intermittent exposure to water



7. The older client asks you if the white rings around her eyes are cancer of the eye or cataracts. What is your best response?


“Yes, they are actually benign tumors and do not need to be removed.”


“No, these rings are a normal change as people age and do not affect vision.”


“No, these rings may be early indications of glaucoma and should be evaluated by your doctor.”


“Yes, these rings are immature cataracts and will need to be removed when they grow large enough to affect your vision.”



8. What is the priority nursing diagnosis for the older adult client who has very thin skin on the backs of the hands and arms?


Risk for Injury


Risk for Infection


Risk for Disuse Syndrome


Risk for Imbalanced Body Temperature: hyperthermia



9. The client has two skin lesions, each the size of a nickel, on his chest. Both lesions are flat and a darker color than the rest of the client's skin. How would you document this finding?


Two 2-cm hyperpigmented patches


Two 1-inch erythematous plaques


Two 2-mm pigmented papules


Two 1-inch moles



10. What technique should you use to obtain a specimen for culture from a client who has crusted skin lesions on the upper back that indicate a possible bacterial infection?


Remove several crusts and swab the underlying exudate.


Remove a crust from the center of the cluster of lesions and send it to the laboratory.


First, dampen the culture swab with sterile water, and then roll the swab over the central crusts.


Apply a gauze bandage to the area, remove it after 1 hour, and send the entire gauze to the laboratory.


Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.

(the instructor has tests & situational tasks)


Student should know:

1. Recall anatomy and physiology of the integument.

2. Describe questions and related rationale used to obtain health history data about the integument.

3. Develop a systematic approach to symptoms analysis for the commonly occurring problems of skin rashes, pain/discomfort, pruritus, and lesions.

4. Identify equipment appropriate to the examination of the integument.

5. Describe the overall approach to assessment of the integument.

6. Identify techniques used on assessing integument.

7. Describe characteristics to be noted in assessing the skin.

8. Describe qualities to be noted in assessing hair.

9. Describe qualities to be noted in assessing nails.

10. Describe expected findings of inspection and palpation of the integument.

11. Name the characteristics that should be described with any skin lesion.

12. Differentiate between primary and secondary lesion.

13. Describe the various types of skin lesion.

14. Identify differences in assessment findings for light and dark skinned clients.

15. Describe common variations (health alterations) that may be found on examination of the integument.

16. Discuss age-related, cultural, and situational considerations related to assessment of the integument.

17. Discuss health promotion practices that are pertinent to the integument.

Student should be able to:

1.    Communication skills with the patient

2.    Demonstrate health assessment of the skin, hair, nails

3.    Using nutritional assessment tools.

4.    Accurately record findings.

Correct answers of test evaluations and situational tasks:

         1.  ANS:                 D

UV light stimulates the production of melanin, which protects against the harmful effects of sun exposure.



         2.  ANS:                 C

The location of the rash suggests contact dermatitis. This condition is most often caused by contact with irritating substances such as might be found in industrial settings or associated with specific hobbies.



         3.  ANS:                 D

Unlike hair growth, which is cyclic, nail growth is a continuous but slow process. Total replacement of a fingernail from the matrix to the end of the finger requires 3 to 4 months.



         4.  ANS:                 C

The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat deposits that show a yellow hue. Foot calluses may appear yellow.



         5.  ANS:                 B

Clubbing of the fingers is never a normal finding and is diagnostic for chronic disorders that impair gas exchange.




         6.  ANS:                 D

The condition, chronic paronychia, is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers.




         7.  ANS:                 B

The rings, or arcus senilis of aging, are fat deposits in the eye that occur with normal aging. Their presence is not indicative of any disorder and does not interfere with vision in any way.



         8.  ANS:                 A

The thinning skin, with a decreased attachment between the dermis and the epidermis, is at an increased risk for injury in response to even minimal trauma or shearing events.



         9.  ANS:                 A

Patches are larger, flat areas of the skin. The information provided does not indicate a mole or the presence of erythema.




       10.  ANS:                 A

The infecting agent is present in the material underneath the crusts. 



Jarvis, C. (2011). Physical examination and health assessment. (6th ed.). Philadelphia: W.B. Saunders

В – Additional:

Weber, J. & Kelley, J., (2010).  Health assessment in nursing. (4th Ed.). Lippincott ISBN: 978-0-781-78160-2

Weber, J. & Kelley, J., (2010).  Health assessment in nursing lab manual. (4th Ed.). Lippincott ISBN: 978-0-781-78161-9

Mosby’s Dictionary of Medicine, Nursing, and Health Professions, 

(2009). (8th ed.) St. Louis: Elsevier ISBN: 9780323052900

Venes, D. editor (2009) Taber’s Cyclopedia Medical Dictionary (21th ed.). Philadelphia: F.A. Davis. ISBN:  9780803615595



Methodical instruction has been worked out by: O. Krekhovska-Lepyavko MD, BSN, MSN



Methodical instruction was discussed and adapted at the Department sitting

June 12, 2013. Minute13

Oddsei - What are the odds of anything.