NURSING ASSESSMENT OF

PHYSICAL SYSTEMS:
Assessing Skin, Hair & Nails

Kennedy C. Bangan, RN, MSN

PHYSICAL ASSESSMENT

• Is an inevitable procedure not just for nurses but

also for doctor.
• Establishing a good assessment would later-on
provide a more accurate diagnosis, planning, and
better interventions and evaluation, that’s why it’s
important to have a good and strong assessment.
1. ASSESSING SKIN, HAIR, & NAILS
Skin

 Largest Organ of the Body

 Protection from environment
 Temperature regulation
 Synthesis of vitamin D
 Storage of fat and blood
 Excretion of waste
 Sensation
 Composed of the Epidermal and Dermal Layers
Skin structure. Three-dimensional view of the skin, subcutaneous
tissue, glands, and hairs.
The Major Functions of the Skin
• Perceiving touch, pressure, temperature, and pain
via the nerve endings
• Protecting against mechanical, chemical, thermal,
and solar damage
• Protecting against loss of water and electrolytes
• Regulating body temperature
• Repairing surface wounds through cellular
replacement
• Synthesizing vitamin D
• Allowing identification through uniqueness of facial
contours, skin and hair color, and fingerprints
Oil or Sebaceous Glands

• Produce Sebum That Is Usually Released in Hair

Follicles
The Major Functions of the Cutaneous Glands

• Excreting uric acid, urea, ammonia, sodium,

potassium, and other metabolic wastes
• Regulating temperature through evaporation of
perspiration on the skin surface
• Protecting against bacterial growth on the skin
surface
The Major Functions of the Cutaneous Glands

• Softening, lubricating, and waterproofing skin and

hair
• Resisting water loss from the skin surface in low-
humidity environments
• Protecting deeper skin regions from bacteria on the
skin surface
Hair

• Thin Fiber Compound of Dead Keratinized Cells

– Vellus
– Terminal
Nails

• Thin Plates of Keratinized Epidermal Cells That

Cover the Distal Ends of Fingers and Toes
Specific Questions

• Illness or infection
• Symptoms
• Pain
• Behaviors
• Infants and children
• Pregnant females
• Older adults
• Environment
Box 11.2 Self-Examination
of the Skin
Removal of:

• Clothing
• Jewelry
• Cosmetics
• Wigs
• Hairpieces
Abnormal Skin Findings

• Primary and secondary lesions

• Vascular lesions
• Purpuric lesions
• Infections
• Malignant lesions
• ABCDE Criteria
ABCDE Criteria for Melanoma Assessment
Potential Secondary Sources for Client Data
Related to the Skin, Hair, and Nails
Spoon Nail are thin and soft and shaped like a little spoon that is often
capable of holding a drop of water. There are many causes, but the most
frequent one is iron deficiency anemia. The medical name for spoon nails is
koilonychia, from the Greek words for hollow (koilos) and nail (onikh).
Hemangioma is an abnormal
buildup of blood vessels on
or under the surface of
the skin. A hemangioma of
the skin may look like a red-
wine or strawberry-colored
plaque, and it may protrude
from the skin.
Port-wine stain (nevus
flammeus) is a discoloration
of the human skin caused
by a vascular anomaly (a
capillary malformation in
the skin). They are so
named for their coloration,
which is similar in color
to port wine, a fortified
red wine from Portugal.
A port-wine stain is
vascular malformation,
seen at birth.
Spider (star) angioma is a type of telangiectasis
(swollen blood vessels) found slightly beneath
the skin surface, often containing a central red
spot and reddish extensions which radiate
outwards like a spider's web.
Venous lake (also known as "Phlebectasis") is a
generally solitary, soft, compressible, dark blue to
violaceous, 0.2- to 1-cm papule commonly found on sun-
exposed surfaces of the vermilion border of the lip, face and
ears. Lesions generally occur among the elderly.
Petechiae  are tiny
purple, red, or brown
spots on the skin. They
usually appear on your
arms, legs, stomach,
and buttocks. You
might also find them
inside your mouth or
on your eyelids.
Purpura also called blood
spots or skin hemorrhages,
refers to purple-colored spots
that are most recognizable on
the skin.
Ecchymosis (bruise) a
discoloration of the skin
resulting from bleeding
underneath, typically caused
by bruising.
Hematoma is a collection of
blood outside of blood
vessels. Most
commonly, hematomas are
caused by an injury to the
wall of a blood vessel,
prompting blood to seep out
of the blood vessel into the
surrounding tissues.
Macule and patch is a flat, distinct, discolored area
of skin less than 1 centimeter (cm) wide. It doesn't
involve any change in the thickness or texture of
the skin. Areas of discoloration that are larger than
or equal to 1 cm are referred to as patches.
Papule and plaque is a small, raised, solid pimple
or swelling, often forming part of a rash on the
skin and typically inflamed but not producing pus.
Nodule and tumor is a growth of abnormal
tissue. Nodules can develop just below the skin.
They can also develop in deeper skin tissues or
internal organs.
Vesicle and bulla  also known as a blister or
a vesicular lesion, forms when fluid becomes trapped
under the epidermis, creating bubble-like sac. The
surrounding skin keeps fluid in place, but the vesicle can
break open very easily and release the fluid.
Wheal is a patch on the skin that is elevated,
discolored, changes shape, and often itches. It can
be due to an insect bite, an adverse reaction to
something that touched your skin, eczema, or
another small puncture wound you experienced.
You may have also heard a skin wheal referred to
as a 'welt' or a 'hive.
Pustule is small bumps on the skin that contain fluid
or pus. They usually appear as white bumps
surrounded by red skin. These bumps look very
similar to pimples, but they can grow quite big.
Cyst is a sac-like pocket of membranous tissue that
contains fluid, air, or other substances. Cysts can
grow almost anywhere in your body or under your
skin. There are many different types of cysts.
Most cysts are benign, or noncancerous.
Skin Atrophy  results from a decrease in the quantity
of collagen fibrils and fibroblasts in the dermis and
leads to a decrease in the thickness of the dermis
noted clinically by thin, translucent skin with more
visible vasculature.
Skin Erosion  is a loss of some or all of the
epidermis (the outer layer) leaving a denuded
surface. Erosion is an eating away of a surface. The
word "erosion" comes from the Latin "erodere"
meaning to eat out.
Lichenification is a skin condition that occurs in
response to excessive itching or rubbing of the skin
and results in thick, leathery patches of skin. This
occurs because the outer layer of skin naturally
thickens with the extra irritation, and it often
happens in tandem with eczema or other skin
disorders.
Scaling Skin is dry, cracked, or flaky skin. Also
known as desquamation, scaling skin happens
when the outer layer of the skin, called the
epidermis, begins to flake off. Scaling skin may arise
when an injury or a medical condition damages the
outer layer of skin.
Crust are dried sebum, pus, or blood usually mixed
with epithelial and sometimes bacterial debris.
Skin Ulcer is an open wound that develops on
the skin as a result of injury, poor circulation, or
pressure. Skin ulcers can take a very long time to
heal. If left untreated, they can become infected and
cause other medical complications.
Skin Fissure is a cutaneous condition in which there
is a linear-like cleavage of skin, sometimes defined
as extending into the dermis. It is smaller than
a skin laceration.
Scar is an area of fibrous tissue that replaces
normal skin after an injury. Scars result from the
biological process of wound repair in the skin, as
well as in other organs and tissues of the body.
Thus, scarring is a natural part of the healing
process.
Skin Lesions

• Tinea
• Measles
• Varicella
• Herpes
• Psoriasis
• Dermatitis
• Eczema
• Impetigo
Tinea corporis is a superficial
dermatophyte infection
characterized by either
inflammatory or non-
inflammatory lesions on the
glabrous skin (i.e. skin
regions other than the scalp,
groin, palms, and soles).
Measles (rubeola) causes a
red, blotchy rash that usually
appears first on the face and
behind the ears, then
spreads downward to the
chest and back and finally to
the feet. Measles is a
childhood infection caused
by a virus. Once quite
common, measles can now
almost always be prevented
with a vaccine.
German measles (rubella) is a
viral infection that causes a red
rash on the body. Aside from the
rash, people with German
measles usually have a fever
and swollen lymph nodes. The
infection can spread from
person to person through
contact with droplets from an
infected person's sneeze or
cough.
Chickenpox (varicella)  is an
infection caused by the
varicella-zoster virus. It causes
an itchy rash with small, fluid-
filled blisters.
Chickenpox is highly
contagious to people who
haven't had the disease or
been vaccinated against it.
Herpes Simplex Virus  is an infection that
causes herpes. Herpes can appear in various parts
of the body, most commonly on the genitals or
mouth. 
Herpes zoster (shingles)  is
viral infection that occurs with
reactivation of the varicella-
zoster virus. It is usually a
painful but self-limited
dermatomal rash. Symptoms
typically start with pain along
the affected dermatome, which
is followed in 2-3 days by a
vesicular eruption.
Psoriasis  is a skin disorder that causes skin cells to
multiply up to 10 times faster than normal. This
makes the skin build up into bumpy red patches
covered with white scales. They can grow
anywhere, but most appear on the scalp, elbows,
knees, and lower back.
Contact dermatitis is a red, itchy rash caused by
direct contact with a substance or an allergic
reaction to it. The rash isn't contagious or life-
threatening, but it can be very uncomfortable. Many
substances can cause such reactions, including
soaps, cosmetics, fragrances, jewelry and plants.
Eczema (atopic dermatitis) is a
condition where patches of skin
become inflamed, itchy, red,
cracked, and rough. Blisters
may sometimes occur.
Impetigo is a common and highly contagious skin
infection that mainly affects infants and
children. Impetigo usually appears as red sores
on the face, especially around a child's nose and
mouth, and on hands and feet. The sores burst
and develop honey-colored crusts.
Malignant Lesions

• Basal cell carcinoma

• Squamous cell carcinoma
• Malignant melanoma
• Kaposi’s sarcoma
Basal cell carcinoma is a type of skin cancer that
most often develops on areas of skin exposed to the
sun. This photograph shows a basal cell
carcinoma that affects the skin on the forehead.
Squamous cell carcinoma is the second most
common form of skin cancer. It's usually found on
areas of the body damaged by UV rays from the
sun or tanning beds. Sun-exposed skin includes the
head, neck, chest, upper back, ears, lips, arms,
legs, and hands. SCC is a fairly slow-growing
skin cancer.
Malignant melanoma is a type of cancer that
develops from the pigment-producing cells known
as melanocytes. Melanomas typically occur in the
skin but may rarely occur in the mouth, intestines or
eye.
Kaposi’s sarcoma  is a cancer that causes patches
of abnormal tissue to grow under the skin, in the
lining of the mouth, nose, and throat, in lymph
nodes, or in other organs. These patches, or
lesions, are usually red or purple.
Abnormal Hair Findings

• Seborrhea
• Tinea capitis
• Alopecia areata
• Infection
– Folliculitis
– Furuncles
• Hirsutism
Seborrheic dermatitis (cradle cap) is a common skin
disease that causes an itchy rash with flaky scales. It
causes redness on light skin and light patches on
darker skin. It's also called dandruff, cradle
cap, seborrhea, seborrheic eczema,
and seborrheic psoriasis.
Tinea capitis (scalp
ringworm) is a disease
caused by superficial
fungal infection of the skin
of the scalp, eyebrows,
and eyelashes, with a
propensity for attacking
hair shafts and follicles
(see the image below).
Alopecia areata  is a
common autoimmune
disorder that often results in
unpredictable hair loss. 
Folliculitis is a common skin
condition in which hair
follicles become inflamed.
It's usually caused by a
bacterial or fungal infection.
At first it may look like small
red bumps or white-headed
pimples around hair follicles
— the tiny pockets from
which each hair grows.
Furuncle/abscess also known as a boil, is a painful
infection that forms around a hair follicle and
contains pus. A carbuncle is collection of boils that
develop under the skin. When bacteria infect hair
follicles, the follicles can swell and turn into boils
and carbuncles. A furuncle starts as a red lump. It
may be tender.
Hirsutism is excessive body hair in men and women
on parts of the body where hair is normally absent
or minimal. It may refer to a "male" pattern of hair
growth that may be a sign of a more serious
medical condition, especially if it develops well after
puberty.
Abnormal Nail Findings

• Spoon nails
• Paronychia
• Beau’s line
• Splinter hemorrhage
• Onycholysis
Spoon nails (Koilonychia)
are thin and soft and
shaped like a
little spoon that is often
capable of holding a drop
of water.
There are many causes,
but the most frequent one
is iron deficiency anemia.
The medical name
for spoon nails is
koilonychia, from the Greek
words for hollow (koilos)
and nail (onikh).
Paronychia is a nail
infection that is an often
tender bacterial or fungal
infection of the hand or
foot, where the nail and
skin meet at the side or the
base of a finger or toenail.
Beau’s line are deep grooved lines that run from side
to side on the fingernail or the toenail. They may look
like indentations or ridges in the nail plate. This
condition of the nail was named by a French physician,
Joseph Honoré Simon Beau (1806–1865), who first
described it in 1846.
Splinter hemorrhages  look like thin, red to reddish-
brown lines of blood under the nails. They run in the
direction of nail growth. They are named splinter
hemorrhages because they look like a splinter under the
fingernail. The hemorrhages may be caused by tiny clots
that damage the small capillaries under the nails .
Onycholysis is a common
nail disorder. It is the
loosening or separation of a
fingernail or toenail from its
nail bed. It usually starts at
the tip of the nail and
progresses back.
Special Considerations

• Developmental, Psychosocial, Cultural, and

Environmental
Developmental Considerations

• Pediatric
– Newborn skin is covered with vernix caseosa.
– Infants have skin that is thin, soft, and free of terminal
hair.
– Milia and “Stork bites” are common, harmless markings
in newborns
– Infants may be born with lanugo present
– Temperature regulation is inefficient in infants.
Milia a milium cyst is a
small, white bump that
typically appears on the
nose and cheeks. These
cysts are often found in
groups.
 Mongolian spots are a type
of birthmark caused by the
pigment in the skin. The
medical term for a
pigmented birthmark such
as a Mongolian spot is a
congenital dermal
melanocytosis.
Developmental Considerations

• Pregnant Female
– Skin pigmentation increases.
– Development of melasma and the linea nigra are
common
Melasma is a common
pigmentation disorder that
causes brown or gray
patches to appear on the
skin, primarily on the face.
The most common areas
for melasma to appear on
the face include: the bridge
of the nose. the forehead.
the cheeks.
Linea nigra (Latin for "black
line"), often referred to as a
pregnancy line, is a linear
hyperpigmentation that
commonly appears on the
abdomen.
Developmental Considerations

• Geriatric
– Skin elasticity decreases with aging
– Sebum production decreases and causes dryness
– Perspiration decreases
– Decrease in melanin production resulting in graying hair
– Increased sensitivity to sunlight
– Nails tend to become thicker and more brittle
Tenting. A. Step 1: Nurse grasps the skin.

A
(continued) Tenting. B. Step 2: Nurse releases
grasp, tenting present.

B
Psychosocial Considerations

• Stress-induced illnesses
• Visible skin disorders and self-esteem/body image
Cultural and Environmental Considerations

• Religion
• Birth anomalies
• Dietary deficiencies
Color Variations in Light and Dark Skin
Coining, Cupping, Pinching
Obese Clients

• Skinfold
• Incontinence
• Hygiene