ordillera Career Development College
College of Health Education
NCM 101
Health Assessment
Winston Terence I. Gonzalo, RN, MAEd
Instructor
ordillera Career Development College
College of Teacher Education
Assessing hair,
skin and nails
Introduction
What system does
the skin, hair and
nails belong to?
Introduction
What is the largest
organ of the human
body?
Introduction
What is the function
of the skin?
Introduction
What are the layers
of the skin?
Introduction
Which part of the
body is the skin
found thickest?
Introduction
Which part of the
body is the skin
found thinnest?
Introduction
What are the glands
found on the skin?
Introduction
Assessment
What are the non-
invasive assessment
techniques?
Assessment
Assessment
What non-invasive
assessment techniques
will be used to assess
skin, hair and nails?
Assessment
Inspection
Assessment
Palpation
Assessment
What types of data do
you collect during
assessment?
Assessment
Subjective data
Subjective data are information
provided by the patient or the
client and are based on their
personal experiences, feelings, or
Assessment
Subjective data
It comes directly from the
individual being assessed and is
often called "symptoms."
Assessment
Subjective data
•Pain level (e.g., "My pain is a 7 out of
10.")
•Fatigue (e.g., "I feel tired all the time.")
•Nausea (e.g., "I have been feeling
nauseous lately.")
Assessment
Subjective data
Subjective data are influenced by the
individual's thoughts, feelings, and
interpretation of their health status. It may
vary from person to person.
Assessment
Objective data
Objective data are measurable and
observable pieces of information obtained
through examination, testing, or
observation. These are often referred to as
"signs."
Assessment
Objective data
It is collected by the healthcare provider
through direct observation, physical
examination, or diagnostic tests.
Assessment
Objective data
•Vital signs (e.g., blood pressure, heart
rate)
•Skin color and temperature
•Laboratory results (e.g., blood tests, urine
analysis)
Assessment
Objective data
•Objective data are more concrete and
less influenced by personal interpretation.
Different healthcare providers should
observe and measure the same objective
data in a consistent manner.
Collecting Subjective
Data
Nursing Health
History
Nursing health history
• History of present health
concern
• Personal health history
• Family history
• Lifestyle and Health Practices
History of present health
concern
• Are you experience any current
skin problems? What are they?
What aggravates the problem?
What relieves it?
History of present health
concern
• Do you have birthmarks or moles?
Describe. Have any of them
changed color, size, or shape?
History of present health
concern
• Have you noticed any change in
your ability to feel pain, pressure,
light touch, or temperature
variations?
History of present health
concern
• Are you experiencing any pain,
itching, tingling, or numbness?
• Are you taking any medications?
How long?
History of present health
concern
• Do you have trouble controlling
body odor? How much do you
perspire?
History of present health
concern
• Have you had any hair loss or
change in the condition of your
hair? Describe.
• Have you had any change in the
condition or appearance of your
nails? Describe.
Personal health history
• Do you recall having severe
sunburn?
• Describe any previous problems
with skin, hair, or nails, including
treatment or surgery.
Personal health history
Personal health history
• Have you had any recent
hospitalization or surgeries?
• Any allergic reactions? To what?
Personal health history
Personal health history
• Have you have fever, nausea
vomiting, GI or respiratory
problems?
Personal health history
• For female clients: Are you
pregnant? Are your menstrual
periods regular?
Personal health history
• Do you have history of anxiety,
depression or any psychiatric
problems?
Family history
• Has anyone in your family had a
recent illness, rash, or other skin
problem or allergy? Describe.
Family history
• Has anyone in your family had skin
cancer?
• Do you have family history of
keloids?
Family history
Lifestyle and Health
Practices
• Do you sunbathe? What protection
do you use?
• Do you perform skin self-exam
once a month?
Lifestyle and Health
Practices
Lifestyle and Health
Practices
• In your daily activities, are you
regularly exposed to chemicals
that may harm the skin (e.g. coal,
tar, pitch, arsenic, etc.)
Lifestyle and Health
Practices
Lifestyle and Health
Practices
• Do you spend
long periods
of time sitting
or lying in one
position?
Lifestyle and Health
Practices
Lifestyle and Health
Practices
• Have you had any exposure to
extreme temperatures?
• Do you have any body piercing?
• Do you have any tattoo?
Lifestyle and Health
Practices
• Have you had any
exposure to extreme
temperatures?
• Do you have any body
piercing?
• Do you have any tattoo?
Lifestyle and Health
Practices
• What is your daily routine in skin,
hair, and nail care? What products
do you use? How do you cut your
nails?
Lifestyle and Health
Practices
Lifestyle and Health
Practices
• What kind of foods do you
consume in a typical day? How
much fluid do you drink each day?
Lifestyle and Health
Practices
• For male, do you have history of
smoking and/or drinking alcohol?
• Do skin problems limit any of your
normal activities?
Lifestyle and Health
Practices
• Describe any skin disorder that
prevents you from enjoying your
relationships?
• How much stress do you have in
your life? Describe.
Case study
• A nurse interviews the client using
specific probing questions.
• The client reports a red rash on her
face. The nurse explores this health
concern using the COLDSPA
mnemonics.
COLDSPA
Mnemonic Question Data provided
Character Describe signs
or symptom.
Onset When did it
being?
COLDSPA
Mnemonic Question Data provided
Location Where is it? Does it
radiate? Does it occur
anywhere else?
Duration How long does it last?
Does it recur?
COLDSPA
Mnemonic Question Data provided
Severity How bad is it?
How much does it
bother you?
Pattern What makes it
better or worse?
COLDSPA
Mnemonic Question Data provided
Associated What other
factors/How it symptoms occur
affects the client with it? How
does it affect
you?
Collecting Objective
data
• Physical examination – provides
data that may reveal local or
systemic problems or alterations
in a client’s self-care activities.
Physical examination
• Local irritation, trauma, or
disease can alter the
condition of the skin, hair, or
nails.
Physical examination
Physical examination
• Systemic problems related to
impaired circulation, endocrine
imbalance, allergic reactions or
respiratory disorder.
Physical examination
Preparing the client
• Ask the client to remove all
clothing and jewelry and put on an
examination gown.
• Remove nail color, artificial nail,
wigs, etc.
Preparing the client
• Let patient sit comfortably on
examination table or bed.
• Ensure privacy by exposing only
the body part being examined.
Preparing the client
Preparing the client
• Room should be well-lit.
• Close doors or draw bed curtains.
• Explain procedure to the client.
• Wear gloves if palpating any
lesions.
Preparing the client
Preparing the client
• Clients from conservative religious
groups may require that the nurse
be same sex as the client.
Equipment
• Examination light
• Penlight
• Mirror client’s self-exam of skin
• Magnifying glass
Equipment
Equipment
• Centimeter ruler
• Gloves
• Examination
gown or drape
Physical assessment
• When preparing to examine the skin, hair and
nails, remember these key points:
• Inspect skin color, temperature, moisture, texture.
• Check skin integrity.
• Be alert for skin lesions.
• Evaluate hair condition: loss or unusual growth.
• Note nail bed condition and capillary refill.
Inspect general skin
coloration
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Inspect general skin Inspection reveals Pallor (loss of color) is
color. Keep in mind that evenly colored skin seen in arterial
the amount of pigment tones without unusual insufficiency, decreased
in the skin accounts for or prominent blood supply, and
the intensity of color as discolorations. anemia. Pallid tones
well as hue. vary from pale to ashen
without underlying pink.
Inspect general skin
coloration
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Cyanosis may cause white
skin to appear blue-tinged,
especially in the perioral,
nail bed, and conjunctival
areas. Dark skin may appear
blue, resulting from
vasoconstriction.
Inspect general skin
coloration
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Central cyanosis results
from a cardiopulmonary
problem, whereas
peripheral cyanosis may
be a local problem
resulting from
vasoconstriction
Inspect general skin
coloration
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Jaundice in light- and
dark-skinned people is
characterized by yellow
skin tones, from pale to
pumpkin, particularly in
the sclera, oral mucosa,
palms and soles.
Inspect general skin
coloration
Inspect general skin
coloration
Inspect general skin
coloration
Inspect general skin
coloration
Inspect general skin
coloration
Inspect general skin
coloration
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Acanthosis nigricans is
roughening and
darkening of skin in
localized areas,
especially the posterior
neck.
Inspect odor
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
While inspecting skin Client has slight or no odor A strong odor of
coloration, note any odors of perspiration, depending perspiration or foul odor
emanating from the skin. on activity. may indicate disorder of
sweat glands. Poor hygiene
practices may indicate a
need for client teaching or
assistance with activities of
daily living.
Inspect for color
variations
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Inspect for color variations. Common variations included Rashes, such as reddish or
Inspect localized parts of the suntanned areas, freckles, or darkened butterfly rash across the
body, noting any color variation. white patches known as vitiligo. bridge of the nose and cheeks,
Generalized loss of pigmentation characteristic of systematic lupus
is albinism. erythematosus.
Erythema (skin redness and
warmth) is seen in inflammation,
allergic reactions, or trauma.
Inspect for color
variations
Inspect for skin integrity
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Check skin integrity. Pay special Skin is intact, and there are no Skin breakdown is initially noted
attention to pressure points reddened areas. as a reddened area on the skin
areas. that may progress to serious and
painful pressure ulcers.
Depending on the color of the
client’s skin, reddened areas may
not be prominent, although the
skin may feel warmer in the are of
breakdown that elsewhere.
Inspect for skin integrity
Inspect for lesions
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Inspect for lesions. Observe the Skin is smooth, without lesions. Lesions may indicate local or
skin surface to detect Stretch marks (striae), healed systemic problems. Primary
abnormalities. scars, freckles, moles, or lesions arise from normal skin due
birthmarks are common findings. to irritation or disease. Secondary
If you observe a lesion: Freckles or moles may be lesions arise from changes in
• Note color, shape, and size of scattered over the skin in no primary lesions. Vascular lesions,
lesion. For very small lesion, particular pattern. reddish-bluish lesions, are seen
use a magnifying glass to note with bleeding, venous pressure,
these characteristics. aging, liver disease or pregnancy.
Inspect for lesions
Inspect for lesions
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
If you observe a lesion: Cancerous lesions can either be
• Note its location, distribution, primary or secondary lesions and
and configuration. are classified as squamous cell
• Measure the lesion with a carcinoma, basal cell carcinoma,
centimeter ruler or malignant melanoma.
If you suspect a fungus, shine a Lesion does not fluoresce. Blue green fluorescence indicates
Wood’s light on the lesion. fungal infection.
Inspect for lesions
Palpate skin to assess
texture
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Palpate skin to assess Skin is smooth and Rough, flaky, dry is seen
texture. Use the palmar even. in hypothyroidism.
surface of the three Obese clients often
middle fingers to report dry, itchy skin.
palpate skin texture.
Palpate skin to assess
texture
Palpate to assess
thickness
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Palpate to assess Skin is normally thin but Very think skin may be
thickness. calluses (rough, thick seen in clients with
sections of the arterial insufficiency or
epidermis) are common in those on steroid
areas of the body that therapy
are exposed to constant
pressure.
Palpate to assess
thickness
Palpate to assess
thickness
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
If lesions are noted when No lesions palpated. Infected lesions may be
assessing skin thickness, put tender to palpate.
gloves on and palpate the Nonmobile, fixed lesions
lesion between the thumb may be cancer.
and index finger for size,
mobility, consistency, and
tenderness. Observe for
draining or other
characteristics
Palpate to assess
thickness
Palpate to assess
thickness
Palpate to assess
thickness
Palpate to assess
moisture
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate to assess moisture. Check Skin surfaces vary from moist to Increased moisture or diaphoresis
under skin folds, and in dry depending on the area (profuse sweating) may occur in
unexposed areas. assessed. Recent activity or a conditions such as fever or
warm environment may cause hyperthyroidism. Decreased
increase moisture. moisture occurs with dehydration
and hypothyroidism.
Clammy skin is typical in shock or
hypotension.
Palpate to assess
temperature
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate to assess Skin is normally a warm Cold skin may accompany
temperature. Use the dorsal temperature. shock or hypotension. Cool
surfaces of your hands to skin may accompany arterial
palpate the skin. disease. Vary warm skin may
indicate febrile state or
hyperthyroidism.
Palpate to assess
temperature
Palpate to assess
temperature
Palpate to assess
mobility and turgor
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate to assess mobility Normally, the skin is mobile, Decrease mobility is seen
and turgor. Ask the client to with elasticity and returns with edema. Decreased
lie down. Using two fingers, to original shape quickly. turgor (a slow return of the
gently pinch the skin over skin to its normal state
the clavicle. taking longer than 30
seconds) is seen in
dehydration.
Palpate to assess
mobility and turgor
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Mobility refers to how Normally, the skin is mobile, Decrease mobility is seen
easily the skin can be with elasticity and returns with edema. Decreased
pinched. to original shape quickly. turgor (a slow return of the
skin to its normal state
Turgor refers to the skin’s taking longer than 30
elasticity and how quickly seconds) is seen in
the skin returns to its dehydration.
original shape after being
pinched.
Palpate to assess
mobility and turgor
Palpate to assess
mobility and turgor
Palpate to detect edema
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate to detect Skin rebounds and does Indentations on the skin
edema. Use your not remain indented may vary from slight to
thumbs to press down when pressure is great and may be in one
on the skin of the feet released. area or all over the
or ankles to check for body.
edema (swelling related
to accumulation of fluid
in the tissue).
Palpate to detect edema
Palpate to detect edema
Inspect the scalp and
hair for general color
and condition
ASSESSMENT PROCEDURE
Inspect the scalp and hair for general
NORMAL FINDINGS
Natural hair color, as opposed to
ABNORMAL FINDINGS
Nutritional deficiencies may cause
color and condition chemically color hair, varies among patchy gray hair in some clients.
clients from pale blond to black to Severe malnutrition in African
At 1-inch intervals, separate the hair gray or white. The color is determined American children may cause a
from the scalp and inspect and by the amount of melanin present. copper-red hair color.
palpate the hair and scalp for
cleanliness, dryness or oiliness, Scalp is clean and dr.. Sparse dandruff Excessive scaliness may indicate
parasites, and lesions. Wear gloves if may be visible. Hair is smooth and dermatitis. Raise lesions may indicate
lesions are suspected or if hygiene is firm, somewhat elastic. infections or tumor growth.
poor.
Inspect the scalp and
hair for general color
and condition
Inspect the scalp and
hair for general color
and condition
Inspect the scalp and
hair for general color
and condition
Inspect the scalp and
hair for general color
and condition
ASSESSMENT PROCEDURE NORMAL FINDINGS
…continuation
ABNORMAL FINDINGS
Dull, dry hair may be seen
with hypothyroidism and
malnutrition. Poor hygiene
may indicate a need for
client teaching or assistance
with activities of daily living.
Inspect the scalp and
hair for general color
and condition
Inspect the scalp and
hair for general color
and condition
ASSESSMENT PROCEDURE NORMAL FINDINGS
…continuation
ABNORMAL FINDINGS
Pustules with hair loss in
patches are seen in tinea
capitis, a contagious fungal
disease (ringworm).
Infection of the hair follicles
(folliculitis) appear as
pustules surrounded by
erythema
Inspect the scalp and
hair for general color
and condition
Inspect amount and
distribution of scalp, body,
axillae, and pubic hair
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Inspect amount and distribution Varying amounts of terminal hair, Excessive generalized hair loss
of scalp, body, axillae, and pubic cover the scalp, axillary, body and may occur with infection,
hair. Look for unusual growth pubic areas according to normal nutritional deficiencies, hormonal
elsewhere on the body. gender distribution. Fine vellus disorders, thyroid or liver disease,
hair covers the entire body except drug toxicity, hepatic or renal
for the soles, palms, lips and failure. It may also result from
nipples. Normal male pattern chemotherapy or radiation
balding is symmetric. therapy.
Inspect amount and
distribution of scalp, body,
axillae, and pubic hair
Inspect amount and
distribution of scalp, body,
axillae, and pubic hair
Inspect amount and
distribution of scalp, body,
axillae, and pubic hair
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
…continuation Patchy hair loss may result from
infections of the scalp, discoid or
SLE, and some types of
chemotherapy.
Hirsutism (facial hair on females)
is characteristics of Cushing’s
disease and results from an
imbalance of adrenal hormones
or it may be a side effect of
steroids.
Inspect amount and
distribution of scalp, body,
axillae, and pubic hair
Inspect nail grooming and
cleanliness
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Inspect nail grooming and Nails are clean and Dirty, broken or jagged
cleanliness. manicured. fingernails may be seen with
poor hygiene. They may also
result from the client’s
hobby or occupation.
Inspect nail grooming and
cleanliness
Inspect nail color and
markings
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
…continuation Yellow discoloration
may be seen in fungal
infections or psoriasis.
Inspect nail grooming and
cleanliness
Inspect nail shape
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Inspect shape of nails. There is normally a 160- Early clubbing (180-degree
degree angle between the angle with spongy
nail base and the skin. sensation) and late clubbing
(greater than 180-degree
angle) can occur from
hypoxia. Spoon nails
(concave) may be present
with IDA.
Inspect nail shape
Palpate nail to assess
texture
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate nail to assess Nails are hard and basically Thickened nails (especially
texture. immobile. toe nails) may be cause by
decreased circulation, and is
also seen in onychomycosis.
Palpate nail to assess
texture
Palpate nail to assess texture and
consistency, noting whether nail
plate is attached to nail bed
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Palpate to assess texture Nails are smooth and firm, Paronychia (inflammation)
and consistency, noting nail plate should be firmly indicates local infection.
whether nail plate is attached to nail bed. Detachment of nail plate
attached to nail bed. from nail bed (onycholysis)
is seen in infection or
trauma
Palpate nail to assess texture and
consistency, noting whether nail
plate is attached to nail bed
Test capillary refill
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
Test capillary refill in nail Pink tone returns There is slow (greater
beds by pressing the immediately to than 2 seconds)
nail tip briefly and blanched nail beds capillary nail bed refill
watching the color when pressure is (return of pink tone)
change. released. with respiratory or
cardiovascular diseases
that cause hypoxia.
Test capillary refill
Sample documentation of
physical examination findings
Skin is pink, intact, without odor. Lesions: nontender, circular,
erythematous papules/plaques with central hypopigmentation and
raised, hyperpigmentation periphery with confluency covering the
bridge of the nose extending to maxillary regions bilaterally, with
sparing of the paraphiltrum region. Skin is smooth, warm and dry.
Turgor with immediate recoil at the clavicle. No edema noted. Hair is
dark brown, shoulder length, clean and shiny. Hair and scalp without
oiliness or parasites. Hair distribution interrupted with five areas of
alopecia, each 2 cm in diameter. Areas exhibit circular, erythematous
papules/plaques with centra hypopigmentation and raised,
hyperpigmentation periphery.
Sample documentation of
physical examination findings
Hair has been removed from legs, axillae, and perineum. Nail beds
are pink. Fingernails manicured with clear enamel. Toenails hard,
smooth, immobile, clean and trimmed. Hard, smooth, and immobile,
forming 160-degree angle at base. Cuticles smooth; no detachment of
nail plate. Capillary refill toes and fingers immediate.
