Skin, hair and nail assessment
Unit 2

Overview

• Asepsis
• Skin assessment
• Hair assessment
• Nail assessment
• Head and Neck Assessment

Asepsis

• Definition

• Types

Medical Asepsis

• Absence of disease producing microorganisms
• Presence of disease producing microorganisms = "contaminated"

Procedures to reduce number of microorganisms and prevent their spread

• 2 million pts acquire an infection each year
• as many as 80,000 people die as a direct or indirect result of these nosocomial infections
• annual treatment cost is over $2.5 billion
• 1/3 of these infections are preventable

According to CDCP

Handwashing

Read Taylor pp 543-544

• Soaps
• Technique
• Time

Gloves for clean technique

• Disposable, non sterile
• Apply as usual
• Removal
• glove to glove
• skin to skin
• Latex allergies

Ok, Now on to Assessment

Anatomy & Physiology

• Structure of the skin
• Functions of the skin
• Protection from microorganisms (Body’s first line of defense)
• Regulation of body temperature
• Secretion of sebum
• Synthesis of Vitamin D
• Transmission of sensations
• Pain
• Touch
• Temperature
• Pressure

Developmental Changes

Newborn

• Skin is diagnostic (component of APGAR score)
• Color at birth and changes indicative of problems
• little sebum (oil) production
• ineffective thermal regulation

minimal sweating, perspiration

Toddler

• More protective against microorganisms
• more resilient
• little sebum, little sweat

School age

• more protective
• still less sebum and sweat compared to adult
• need Hx immunizations

(is rash a communicable disease?)

Adolescent

• Qualities similar to adult
• Sebaceous glands become active, skin is more oily
• Acne
• Eccrine sweat glands become active
• Development of body hair
• Apocrine sweat glands become active

Adult skin changes

• Older adult
• Lose subcutaneous and adipose tissue
• Epidermis thins and flattens
• Elasticity, turgor decrease
• Wrinkles
• Decreased sweating
• Increased sensitivity to cold
• Hair becomes dry and gray

Men- lose hair
Women- > facial hair

Older adult skin changes

• More prone to skin cancer
• See benign skin lesions
• Lantigines - flat macules  "liver spots", "age spots"
• Seborrheic keratosis - raised, dark, "warty"
• Senile or actinic keratoses

on exposed skin small, red; become raised, rough, brown

• Cherry angiomas
• Axillary and pubic hair thins
• Finger nails lose luster
• Toenails may thicken, split

Assessment of the skin, hair & nails

• Skin 

hygiene habits 
recent changes
history of sun exposure

• Hair 

hygiene habits
recent loss
change in character of hair

• Nails 

change in character

• If changes are reported in history questions
• location
• frequency
• sequence and chronology
• quantity
• quality
• setting
• associated phenomena
• aggravating & alleviating factors

Assessment techniques for skin, hair, nails ???

• Inspection
• Palpation

• do exposed areas first
• then as proceed with PE

Skin Inspection

Equipment

• Warm hands
• Transparent ruler
• Bright (prefer sun) light

Color

• SYMMETRY
• Intactness
• General hygiene
• Lesions

Skin Palpation

• temperature/moisture
• texture
• turgor
• edema
• capillary refill

Inspect and Palpate

• Lesions and masses
• location (distribution)
• pattern (configuration)
• size, shape
• mobility
• consistency
• type
• primary
• secondary
• vascular

Skin Lesions

• location (distribution) and
• pattern (configuration)

• Classification
• Primary - arise from previously normal skin
• Secondary - result from change in primary
• Vascular - may be normal at different times throughout life span

Primary types

• macule
• patch
• papule
• plaque
• nodule
• tumor
• wheal
• vesicle
• bulla
• pustule
• cyst

Secondary types

• erosion
• ulcer
• keloid (hypertrophied scar)
• striae (stretch mark)

ABCD rule

• Asymmetry
• Border irregularity
• Color: mottled, pigmentation varies
• Diameter:increases, > 6mm (pencil eraser)

Vascular skin lesions

• Bleeding into skin: petechia(ae) deep red, flat, 1-3 mm ecchymosis
• hemangioma: nevus

• cherry angioma ruby red, 1-3 mm, may be raised

• spider angioma fiery red, > 2 cm, may be NL

• venous stars

Other descriptive terms

• Atrophy - thinning, shiny skin

• Excoriation - injury caused by abrasion
• Scar - injured tissue replaced by fibrous tissue (red>purple>white)
• Pruritus - itching

Hair Inspection & Palpation

• distribution
• quantity
• texture
• color
• oily, dry
• hygiene
• changes

Nail Inspection & Palpation

• color/markings
• thickness
• shape/curvature
• skin around nails
• surface/texture
• adhesion
• angle between nail and nail bed should be 160^o > 180^o - clubbing

Factors affecting skin integrity

• Developmental level
• reflects ability to care for self
• Personal preferences
• water temperature
• lotions, soaps
• Health state
• Circulation
• < tissue perfusion, < nutrients
• decreased venous circulation

• Impaired physical mobility
• ability to change positions
• pressure points
• circulation
• Mechanical devices
• Altered sensation
• Presence of secretions
• irritation
• harbors microrganisms
• prone to breakdown
• Altered hydration
• dry skin has < turgor
• increased susceptibility to shearing forces
• Altered nutrition
• Amount of sun exposure

Nursing Diagnoses

• Impaired skin integrity
• Altered peripheral tissue perfusion
• Body image disturbance
• Self-care deficit: hygiene
• Pain related to incision
• Risk for infection related to incision
• Risk for Impaired skin integrity

Risk for Impaired Skin Integrity related to

• < circulation
• < sensation
• obesity
• immobility
• malnutrition
• incontinence
• agitation
• sun exposure

Health Promotion and Counseling

• Sun/UV exposure