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    Assessment of Skin Nursing

    Uploaded by

    Maria Es
    The document provides guidance on assessing hair, skin, and nails by describing the normal findings and abnormalities to look for in each area. The assessment involves inspecting and palpating the skin for color, temperature, texture, moisture, and lesions. Hair is inspected for color, amount, and scalp lesions. Nails are inspected for color, texture, shape, condition of nail beds, and capillary refill. Common abnormalities found in skin, hair, and nails that may indicate underlying health issues are described. The assessment is meant to be performed systematically while ensuring patient privacy and comfort.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Assessment of Skin Nursing

    Uploaded by

    Maria Es
    151 views36 pages
    The document provides guidance on assessing hair, skin, and nails by describing the normal findings and abnormalities to look for in each area. The assessment involves inspecting and palpating the skin for color, temperature, texture, moisture, and lesions. Hair is inspected for color, amount, and scalp lesions. Nails are inspected for color, texture, shape, condition of nail beds, and capillary refill. Common abnormalities found in skin, hair, and nails that may indicate underlying health issues are described. The assessment is meant to be performed systematically while ensuring patient privacy and comfort.

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    Assessment of skin nursing

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    The document provides guidance on assessing hair, skin, and nails by describing the normal findings and abnormalities to look for in each area. The assessment involves inspecting and palpating the skin for color, temperature, texture, moisture, and lesions. Hair is inspected for color, amount, and scalp lesions. Nails are inspected for color, texture, shape, condition of nail beds, and capillary refill. Common abnormalities found in skin, hair, and nails that may indicate underlying health issues are described. The assessment is meant to be performed systematically while ensuring patient privacy and comfort.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    151 views36 pages

    Assessment of Skin Nursing

    Uploaded by

    Maria Es
    The document provides guidance on assessing hair, skin, and nails by describing the normal findings and abnormalities to look for in each area. The assessment involves inspecting and palpating the skin for color, temperature, texture, moisture, and lesions. Hair is inspected for color, amount, and scalp lesions. Nails are inspected for color, texture, shape, condition of nail beds, and capillary refill. Common abnormalities found in skin, hair, and nails that may indicate underlying health issues are described. The assessment is meant to be performed systematically while ensuring patient privacy and comfort.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 36

    Assessment of Hair, Skin

    and Nails
    Assessment of Hair, Skin and
    Nails
    Equipment:
    - Penlight
    - Skin marker
    - Ruler
    - Clean gloves
    - Mask
    - Magnifying glass
    - Examination gown and drape
    Preparation:

    • Adequate lighting
    • Comfortable room temperature
    • Introduce self; verify client’s identity;
    • Explain the procedure; its purpose
    and how the client can cooperate.
    • Provide privacy
    • Perform hand hygiene
    • Don gloves
    • Have the client remove all clothing (that
    includes socks and shoes) from the
    waist up and put on examination gown
    or drape.
    • Ask the client to sit in an upright
    position with arms relaxed at the sides.
    Procedure
    SKIN Normal Findings
    Inspect In white skin: Light to dark pink
    skin for color In dark skin: Light to dark brown,
    Olive
    ABNORMAL findings:
    Pallor – arterial insufficiency,
    decreased blood supply, and
    anemia.
    Brown skinned – yellowish
    brown tinge
    Black skinned – ashen gray
    Procedure
    SKIN ABNORMAL findings:

    Most evident in the conjunctiva,


    oral mucous membranes,
    nail beds, palms of hands &
    soles of feet.
    Cyanosis - vasoconstriction; MI,
    or pulmonary insufficiency.
    Jaundice – liver disease, RBC
    hemolysis
    Erythema –redness & warmth
    fever; inflammation
    Procedure
    SKIN Normal Findings
    Inspect & Silver-pink stretch marks (striae),
    palpate any moles, freckles, birthmarks
    skin lesions
    Abnormal findings:
    Macule – flat & colored; Petechia
    Abnormal findings:

    Papule – Elevated and superficial (Mole)


    Abnormal findings:

    Pustule– Elevated & filled with pus (Acne)


    Abnormal findings:

    Bulla, vesicle – elevated & filled with fluid.e.g.


    Blister; glows when trans illuminated w/ penlight
    Abnormal findings:

    Wheal– localized edema (Insect bite)


    Abnormal findings:

    Cyst – encapsulated, filled with fluid or


    semisolid mass (epidermoid cyst)
    Abnormal findings:

    Nodule/Tumor – elevated and firm, has


    dimension of depth(e.g.Lipoma)
    • If lesion is detected, inspect and
    palpate for size, location and mobility,
    consistency, and pattern (circular,
    clustered, or straight lined)
    • Asymmetric borders on a skin lesion
    suggest the lesion is malignant.
    Procedure
    SKIN Normal Findings
    Palpate to Warm
    assess
    Temperature
    ABNORMAL findings:
    Use the cold skin – shock, hypotension
    dorsal very warm – Fever,
    surfaces of hyperthyroidism
    the hands to
    palpate the
    skin
    Procedure
    SKIN Normal Findings
    Observe & Dry, Moisture in skin folds and
    palpate skin axillae ( varies with environmental
    Moisture temp & humidity & activity)
    ABNORMAL findings:
    Excessive moisture - Hyperthermia
    Excessive dryness - DHN
    Procedure
    SKIN Normal Findings
    Palpate for: Smooth, soft
    texture

    ABNORMAL findings:
    Dry - hypothyroidism
    Excessive dryness - DHN
    Procedure
    SKIN Normal Findings
    Press firmly No swelling, pitting or edema
    for 5-10secs
    over tibia &
    ankle
    ABNORMAL findings:
    Swollen, shallow to deep pitting-
    ascites;
    Generalized edema – CHF
    localized edema- vascular
    problems
    Scale for edema

    1+ barely detectable (2mm)


    2+ indentation of 2-4mm
    3+ indentation of 5-7mm
    4+ indentation of more than 7mm
    Procedure
    SKIN Normal Findings
    Assess skin Skin pinches easily & immediately
    for mobility* returns to its original position.
    and turgor*
    ABNORMAL findings:
    Ask pt. to lie Decreased mobility-edema
    down, pinch Decreased turgor (slow return of
    skin on the the skin to its normal state, taking
    sternum or longer than 30 seconds.) -DHN
    under the
    clavicle.
    Procedure
    HAIR, Normal Findings
    SCALP
    Inspect hair varies
    for color,
    amount and
    distribution
    ABNORMAL findings:
    Patchy gray areas-nutritional
    deficiencies
    Copper red hair-malnutrition
    Sudden hair loss - Alopecia
    ↑ in facial hair in women-Hirsutism
    Procedure

    HAIR, ABNORMAL findings:


    SCALP Patchy hair loss – Systemic Lupus
    erythematosus

    Normal Findings
    Assess for none
    presence of
    parasites
    Procedure
    HAIR, SCALP Normal Findings

    Inspect for presence of none


    scalp lesions

    At 1-inch intervals,
    separate the hair from the
    scalp and inspect and
    palpate scalp with
    cleanliness and
    orderliness
    Procedure
    NAILS Normal Findings

    Inspect Pink nail bed


    Color
    ABNORMAL findings:
    Pale or cyanotic –hypoxia
    Yellow discoloration – fungal
    infxn or psoriasis
    Splinter hemorrhages(vertical lines)
    -trauma
    Beau’s lines (Horizontal)-trauma;
    zinc deficiency, DM, CHF
    Assessment of Hair, Skin and
    Nails
    Beau’s lines
    Splincter hemorrhage
    NAILS Normal Findings

    Inspect Round, hard, immobile


    texture
    ABNORMAL findings:
    Thickened – decreased circulation
    Normal findings
    shape Round with 160 degree angle
    between the nail base and the skin
    ABNORMAL findings:
    Clubbing 180 degree or more –
    hypoxia
    Procedure
    NAILS Normal Findings

    ABNORMAL findings:

    White spots – zinc deficiency


    Spoon shaped nails – iron
    deficiency
    Spoon nails
    Clubbing of nails
    NAILS Normal Findings

    Inspect Smooth, firm and pink


    condition
    of nail beds
    ABNORMAL findings:
    inflammed nail bed – Paronchia
    Detached nail plate from nail bed
    –Onycholysis (infection, trauma)
    NAILS Normal Findings

    Perform Pink tone returns immediately to


    blanch test blanched nail beds when pressure
    for capillary is released.
    refill
    ABNORMAL findings:
    There is slow (greater than 2
    seconds capillary nail bed refill
    (return of pink tone) may indicate
    with respiratory or cardiovascular
    diseases that cause hypoxia.
    Paronchia (Hang nails)
    Onycholysis
    • End of discussion

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