Skin, Hair & Nails

Question 1


Throughout the assessment process the nurse collects?

Answer 1

objective data

subjective data

Question 2

Techniques used?

Answer 2

inspection

palpation

Question 3

When does assessment start?

Answer 3

the moment you see the patient

Question 4

Factors to be Considered?

Answer 4

Age
Developmental Level
Race Ethnicity-different skin pigmentations
Work History-damage from sun exposure
Social economics-unable to buy healthy food
Psychosocial considerations- pulling out hair, biting nails,
Self-care practices/preferences-brittle nails due to smoking

Question 5

lenugo?

Answer 5

fine baby hair

Question 6

Mongolian spot?

Answer 6

red/purple/blue spot on buttocks/sacrum. found more in asian, african babies

Question 7

White spots on baby’s nose

Answer 7

sebum that has accumulated

Question 8

Physical Assessment: SKIN?

Answer 8

1. Inspection of the skin
   Cleanliness
   (Why?) can indicate person’s job, development of infections

Odour
(Why?) indication of their diet, pathology (disease process/infections)

Skin Tone

(Why?) document skin tone properly

Assess for even pigmentation- should be even

Assess for superficial vient and arteries

Assess for scarring, rashes, moles, birthmarks, etc… Why?
(age of scar, signs of infection, location, pt understanding of scar)

Rashes: can be cause by stress, location can mean a lot.

weeping = leaky rash

Inspect for skin bruising, burns, tatoos, piercings, etc…
color of bruise determines age of it.
Abnormal bruising cal indicate blood clotting

Inspect for infestations

Question 9

Assess moles using ABCDE rule:

Answer 9

Assess moles using ABCDE rule:
A: asymmetry
B: border irregularity
C: colour variation
D: diameter
E: elevation and enlargement

Question 10

Palpation of the Skin?

Answer 10

2. Palpation of the Skin

Determine patients skin temperature
 How do we do this?


-use dorsal side of hand on both sides of body, working from top to bottom. sides should be even in temperature

Assess amount of moisture on skin surface
How should the skin feel?

-dry or oily depending on location

Palpate for skin texture
 How should the skin feel?

-smooth and dry but not flaky

Palpate for skin thickness

Palpate for skin elasticity
Turgor=elasticity (How do we assess Turgor??)- pinch back of hand

Palpate/Inspect for Edema-press finger into skin for 5 seconds. measured on scale 1-4 +1 = 2mm +4 = 8 mm

Palpate/Inspect skin lesions

Two types of lesions
Primary lesions:
(eg. Vesicles) shingles, chicken pox

Secondary lesions:
(eg. Ulceration) primary lesion that popped

Question 11

Palpate for skin for sensitivity

Answer 11

If skin is sensitive to touch, which assessment should you perform on the patient at this time?

• What questions would you ask the patient?

do they have any pain, discomfort, sensitivity (OPPQRRSTU)

Question 12

Are there any skin assessment tools?

Answer 12

Braden scale:

Use the Braden Scale to assess the patient’s level of risk for development of pressure ulcers.

The evaluation is based on six indicators: 
sensory perception, 
moisture,
activity, 
mobility, 
nutrition, 
friction or shear.

Question 13



Physical Assessment: HAIR



Answer 13

1. Inspection
   Cleanliness

Hair colour

Amount and distribution of hair throughout the scalp & body

Inspect dryness, lesions

pattern baldness is normal

Inspect for dandruff, cradle cap (sebum forms hard crust on infants scalp)

Inspect for infestation: lice

2. Palpation
   Texture of hair

Question 14

Physical Assessment: NAILS


Answer 14

Inspection: 
Inspect for hygiene
Inspect the cuticles
Inspect colour of natural nail = even, pink undertone
Inspect the nails for shape and contour 

-peripheral vascular disease causes hard yellow nails due to lack of blood flow

Inspect for clubbing

What is clubbing?
Clubbing: is a deformity of the fingers and fingernails associated with a number of diseases, mostly of the heart and lungs.

What causes clubbing of the fingernails?
-prolonged hypoxia or could be the normal formation of nail. related to heart and lung disease

Inspect for nail spooning: (related to iron deficiency)

Spoon-shaped or spooning fingernails refers to a concavity in the fingernail itself, resulting in a depression in the nail that gives an appearance of a spoon shape to the entire nail.

2. Palpation
   Assess cap refill….How and Why

blanching when pressing on nail. color should come back when pressure is released (<2 sec)

Palpate to determine thickness, regularity and attachment to nail bed

Cap refill: perfusion of blood to capillaries