Physical Assessment

Skin, Hair, and Nails

Ibrahim R. Ayasreh RN, ACNS, MSN

Anatomy of skin

Anatomy of skin
Skin contains three layers : - Epidermis: the most superficial thin layer, and devoid of blood vessels. - Dermis: is well supplied with blood. It contains connective tissue, sebaceous glands, sweat glands, and hair follicles. - Subcutaneous or adipose tissues.

Appendages of skin
Hair, nails, and sebaceous and sweat glands are considered appendages of the skin. Adults have two types of hair: vellus hair, which is short, fine, inconspicuous, and relatively unpigmented; and terminal hair, which is coarser, thicker, more conspicuous, and usually pigmented.

Appendages of skin
Sebaceous glands produce a fatty substance that is secreted to the skin surface through the hair follicles. Sweat glands are of two types: eccrine and apocrine. The eccrine glands are widely distributed, open directly onto the skin surface, and by their sweat production help to control body temperature. In contrast, the apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress

Color of skin
The color of normal skin depends primarily on four pigments: melanin, carotene, oxyhemoglobin, and deoxyhemoglobin. Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles. Abnormal colors of skin are : pallor, redness, cyanosis, and jaundice.

Functions of Skin
Keep the body in homeostasis despite the daily assaults of the environment. It provides boundaries for body fluids. Protecting underlying tissues from microorganisms, harmful substances, and radiation. It modulates and regulates body temperature. It synthesizes vitamin D.

Anatomy of Nails

Physical Examination of Skin

By inspection and palpation the nurse can observe theses characteristics: 1. Color. 2. Moisture. 3. Temperature. 4. Texture. 5. Mobility & turgor. 6. Lesions.

Physical Examination (color of skin)

During inspection of skin, look for: - Increased pigmentation. - Decreased pigmentation. - Pallor. - Redness. - Cyanosis. - Jaundice.

Physical Examination (color of skin)

Redness and pallor are best assessed at the fingernails, the lips, and the mucous membranes, particularly those of the mouth and the palpebral conjunctiva. Redness is usually caused by increased oxyhemoglubin such as in polycythemia.

Pallor

Lack of Oxyhemoglubin

Anemia

Decreased blood flow, such as in arterial insufficiency

Cyanosis Central
Best assessed in the lips, tongue, and oral mucosa

Peripheral
Best assessed in the extremities, nails.

Usually seen in advanced lung disorders, congenital heart diseases, and abnormal hemoglobins, and sometimes in congestive heart failure.

May be normal response to cold and anxiety. But abnormally it may be seen in congestive heart failure.

Central Cyanosis

Peripheral Cyanosis

Jaundice
Yellowish color of skin Best assessed at sclera, Palpebral conjunctiva, hard and soft palate, tympanic membrane and skin.

Jaundice suggests liver disorders or excessive hemolysis of RBCs.

Jaundice

Physical Examination (Moisture of skin)

Increased moisture or diaphoresis (profuse sweating) may occur in conditions such as fever or hyperthyroidism.
Decreased moisture occurs with dehydration or hypothyroidism

Physical Examination (Temperature of skin)

Use the back of your hand to assess the temperature of skin. Generalized warmth in fever, hyperthyroidism. Coolness in hypothyroidism or may accompany arterial disease. Local warmth of inflammation or cellulitis.

Physical Examination (Texture of skin)

Examples are roughness and smoothness. Roughness usually seen in hypothyroidism

Physical Examination (Mobility & turgor of skin)

Mobility is assessed by lifting a fold of skin and note the ease with which it lifts up. Turgor is assessed noting the speed with which it returns into place.
Decreased mobility in edema, scleroderma. Decreased turgor in dehydration.

Physical Examination ( Lesions of skin )

Observe any lesions of the skin, noting their characteristics: 1. Anatomic location & distribution : Are they generalized or localized? 2. Arrangement: are they linear, clustered, annular (in a ring), arciform (in an arc), or dermatomal. 3. Type of lesion: are they primary or secondary. 4. Color of lesion.

Primary Lesions

Primary Lesions

Primary Lesions

Primary Lesions

Primary Lesions

Primary Lesions

Secondary Lesions

Secondary Lesions

Scalp and Hair

Natural hair color, as opposed to chemically colored hair, varies among clients from pale blond to black to gray or white. At 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions

Scalp and Hair

Excessive scaliness may indicate dermatitis. Raised lesions may indicate infections or tumor growth. Dull, dry hair may be seen with hypothyroidism and malnutrition.

Scalp and Hair

Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure, chemotherapy or radiation therapy. Patchy hair loss may result from infections of the scalp. Hirsutism (facial hair on females) is a characteristic of Cushings disease.

Nails
Inspect and palpate the nails and note: - Nail grooming and cleanliness - Color. - Shape. - Texture and Consistency. - Capillary refill. - Any lesions.

Color of Nails
Pink tones should be seen. Some longitudinal ridging is normal. Pale or cyanotic nails may indicate hypoxia or anemia.

Splinter hemorrhages may be caused by trauma.

Yellow discoloration may be seen in fungal infections or psoriasis.

Shape of Nails
There is normally a 160-degree angle between the nail base and the skin. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia

Capillary refill
Test capillary refill in nailbeds by pressing the nail tip briefly and watching for color change. There is slow (greater than 2 seconds) capillary nailbed refill (return of pink tone) with respiratory or cardiovascular diseases that cause hypoxia.