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Physical assesment of the skin and nails

Frances Rose L. Alcaraz

BS Clinical Pharmacy

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SKIN largest organ of the body

created by special cells called melanocytes

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SKINMAJOR FUNCTIONS:

a. Protection

b. Sensationc. Insulation

- Adipose tissue

- Arrector pili muscles- Sweat glands

d. Temperature regulation

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SKINTHREE LAYERS:

Epidermis

Dermis

Hypodermis

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FIVE DIFFERENT LAYERS

OF EPIDERMIS

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nail

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NAIL

Free

edge

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PHYSICAL

ASSESSMENT ofskin and nails

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ASSESSMENT

To prepare for the skin and nail examination:

remove all clothing and jewelry

remove nail enamel, artificial nails, wigs, toupees, or

hairpieces

have the client sit comfortably

ensure privacy by exposing only the body part being

examined

keep the room door closed or the bed curtain drawn

explain what you are going to do

answer any questions the client may have

wear gloves when palpating any lesions

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ASSESSMENT

Equipment and supplies:

a. Examination light b. Penlight c. Mirror

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ASSESSMENT

Equipment and supplies:

d. Magnifying glass e. Centimeter ruler f. Gloves

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ASSESSMENT

Equipment and supplies:

g. Woods lamp h. Examination gown or drape

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ASSESSMENT

Obtain a history of the patient's skin condition.

Go over the detailed family history with the patient or patient's

family.

Also obtain a history of the patient's bathing routine and skin

care products.

Ask the patient:

* about skin changes

* if skin appearance changes with the seasons

* about any changes in nail

* about allergies

Document your findings in the medical record.

http://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_06928151958_chapter9%20skin%20hair.pdf

http://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_06928151958_chapter9%20skin%20hair.pdfhttp://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_06928151958_chapter9%20skin%20hair.pdf

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ASSESSMENT

REMEMBER:

COLDSPA

CHARACTER: Describe the sign or symptom.How does it feel, look, sound, smell, and so forth?

ONSET: When did it begin?

LOCATION: Where is it? Does it radiate?

DURATION: How long does it last? Does it recur?

SEVERITY: How bad is it?

PATTERN: What makes it better: What makes it

worse?

ASSOCIATED FACTORS: What other symptoms

occur with it?

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Skin

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Skin

SKIN

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SKINEvaluation:

1. Inspectiona. color

NORMAL: pinkish; appropriate for race & even pigmentation

PALLOR

CYANOSIS

REDNESS

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SKINa. color

YELLOWNESS DARKENING W/ LINEAR

STREAKLIKE

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SKINb. pigmentation c. rashes

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SKIN

d. lesions

e. trauma

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SKINf. note the distribution, amount and texture of the

body hair

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SKINEvaluation:

2. Palpation

a. mobility- how easily the skin can be pinched (edema)

b. turgor- skins elasticity and how quickly the skin returns to

its original shape after being pinched (dehydration)

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SKINc. edema

Assessment Chart for Pitting Edema adapted from the Guelph General Hospital Congestive Heart Failure Pathway

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SKINd. Thickness (thick & thin)

e. moistness

SKIN

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SKINf. temperature

TERMS DEFINITIONS

temperature increase increase in blood flow to dermis

causes this

temperature increase, localized burns or localized infections cause this

temperature increase, generalized fever causes this

temperature decrease decrease in blood flow to dermis

causes this

temperature decrease, localized arteriosclerosis causes this

temperature decrease, generalized shock causes this

lack of bilateral symmetery of

temperature

indicates circulatory problems or

infection

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BEDS

Evaluation:

1. Inspection

NORMAL: nails are white or light pink and have a narrow normal pink

band near the end of the fingernail.

a. Inspect nail grooming

and cleanliness

Normal: Clean and manicured

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BEDS

b. Inspect nail color and markings

Normal: Pink tones should be seen. Some longitudinal ridging is normal

cyanosis pale

splinter

hemorrhages

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BEDS

Yellow

discoloration

Nail pitting

Beaus nails

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BEDS

c. Inspect shape of nails

Normal: There is normally a 160-degree angle between the nail base and the skin

clubbing

spoon nails

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BEDS

Evaluation:

2. Palpation

a. Palpate nail to assess texture

Normal: Nails are hard and basically immobile. Dark-skinned clients may have thicker nails. Older

clients nails may appear thickened, yellow, and brittle because of decreased circulation in the

extremities.

thickened nails

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BEDS

b. Palpate to assess texture and consistency, noting

whether nail plate is attached to nail bed

Normal: Smooth and firm; nailplate should be firmly attached to nailbed.

paronychia oncholysis

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BEDS

c. Test capillary refill in nail beds by pressing the nail

tip briefly and watching for color change.

Normal: Pink tone returns immediately to blanched nailbeds when pressure is released.

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SKIN

terminologies

SKIN l i

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SKIN lesionsPRIMARY LESIONS

a. Bulla (scarlet fever /sunburn)

- large (>1cm)

- circumscribed- elevated lesion

containing fluid

b. Ecchymosis (vasculitis,leptospirosis, endocarditis)

- large (>1cm) hemorrhage

- bruise

SKIN l i

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SKIN lesionsc. Macule (rubella, scarletfever, roseola infantum)

- small (1cm) solid lesion- below, even with or above

the surface

- more deeply rooted than a

papule

SKIN l i

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SKIN lesionse. Papule (dermatitis, psoriasis,ringworm, chicken pox, eczema)

- small (

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SKIN lesionsg. Petechia (severe systemicdisease)

- small (1cm)

- flat-topped and elevated

above the skin surface

- often formed by coalescenceof papules

SKIN l i

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SKIN lesionsi. Pustule (acne, impetigo, boils,Stap. infections)

- circumscribed

- elevated lesion of varying

size containing pus

j. Vesicle (insect bites, chemicalirritations, herpes)

- small (

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SKIN lesionsi. Wheal (mosquito bites or hives)

- edematous

- transitory papule

- evanescent

SKIN l i

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SKIN lesionsSECONDARY LESIONS

a. Crust (infectious dermatitis)- dried collection of blood,

serum, or pus from corrosive

lesion

b. Excoriation- scratch mark usually

covered with blood or serous

crusts

SKIN l i

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SKIN lesionsc. Fissure (skin dryness)

- vertical, linear crack

through the epidermis anddermis

d. keloid- firm raised mass of scar tissue at the

previous site of a wound

- growth of extra scar tissue where

the skin has healed after an injury

SKIN l i

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SKIN lesionse. Lichenification(dermatitis)

- roughening & thickening ofthe epidermis and dermis

f. scale (dandruff, fungalinfections, psoriasis, seborrheic dermatitis)

- Dead epidermal cells

SKIN l i

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SKIN lesionsg. Ulcer(acute or chronicconditions)

- lesion that involves loss of

the upper portion of the skinand part of the lower portion

h. scar- normal skin tissue has beenreplaced by connective tissue

SKIN l i

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SKIN lesionsOTHER LESIONS

a. comedo- Open comedone or

Blackhead

- small, flesh-colored papulewith a central orifice containing

a dark plug

b. millium- Closed comedone or

Whitehead

- small, pale-colored papulewith no visible opening

SKIN l i

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SKIN lesionsc. nervus

- mole

- flat or elevated pigmented

lesion

d. Oslers node (endocarditis)- small, raised, discolored, tender

lesion on the pads of the fingers andtoes

SKIN l i

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SKIN lesionse. Telangiectasias

- dilated superficial bloodvessels

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FINGERNAIL AND

TOENAILterminologies

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BEDSa. Beaus lines

(malnutrition)

- transverse horizontal

depression associated withsevere illness

b. Clubbing (hypoxia andCOPD)

- Increased angle (>180 degrees)

between the base of the nail and

the nail bed

- associated with chronic arterial

desaturation

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BEDS

c. Koilonychia (IDA)- spooning of the nails

d. Onycholysis (trauma,malnutrition, thyroid disease)

- detachment of nail plate from nail

bed

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BEDS

e. Splinter haemorrhages- red or brown linear streaks in the distal extremity of the nail bed

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References http://www.eucerin.com/skin-expertise/about-the-skin/the-skin-and-its-

cells/the-epidermis/. Retrieved August 10,2013.

http://sketchymedicine.com/2012/11/layers-of-the-epidermis/.Retrieved

August 10,2013

http://dermatology.about.com/od/glossaryl/g/langerhans.htm.Retrieved

August 10,2013 http://www.webmd.com/skin-problems-and-treatments/picture-of-the-

skin.Retrieved August 10,2013

http://www.clinimed.co.uk/Wound-Care/Education/Wound-

Essentials/Structure-and-Function-of-the-Skin.aspx. Retrieved August

10,2013

http://faculty.stcc.edu/AandP/AP/AP1pages/Units1to4/skin/skin1.htm.

Retrieved August 10,2013

http://medical-dictionary.thefreedictionary.com/Skin+Lesions. Retrieved

August 10,2013

http://www.siumed.edu/medicine/dermatology/student_information/skinphysi

calexam.pdf. Retrieved August 10,2013

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