NCM 101
HEALTH ASSESSMENT
Genalin S. Amuan, RN
Physical Assessment
1. Skin, Hair and Nails
2. Head and Neck
3. Eyes
4. Ears
5. Mouth, Throat, Nose, and Sinuses
6. Thorax and Lungs
7. Breast and Lymphatic System
8. Heart and Neck Vessels
9. Peripheral Vascular System
Skin, Hair and Nail Assessment
Skin
▪
largest organ
▪
physical barrier that protects the underlying tissues and structures temperature maintenance
▪
fluid and electrolyte balance
▪
absorption
▪
excretion
▪
sensation
▪
immunity
▪
vitamin D synthesis
Structure and Function of Skin
▪
While the skin primarily acts as a barrier to prevent the entry of many substances into the body, it is still capable of
absorbing certain substances, especially under specific conditions.
▪
The outermost layer of the skin, called the stratum corneum, is relatively impermeable to most molecules. However, the
skin can absorb:
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Water: The skin can absorb water to some extent, especially if it is in contact with water for prolonged periods.
This is why prolonged immersion in water, such as during bathing, can lead to skin wrinkling
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Some Gases: Certain gases can be absorbed through the skin, though the extent varies. For example, oxygen
and carbon dioxide can diffuse through the skin.
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Topical Medications: The skin is commonly used as a route for drug administration. Many medications, such as
creams, ointments, and patches, are designed to be applied to the skin, allowing for absorption of the drug into
the bloodstream.
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Certain Chemicals: Some chemicals, especially those with smaller molecular sizes and specific properties, can
be absorbed through the skin. However, not all chemicals can penetrate the skin barrier easily.
●
Epidermis – outer layer, composed of 4 distinct layers
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Stratum corneum - outermost layer , consists of dead, keratinized cells that render the skin waterproof (replaced every 3-4
weeks)
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Stratum lucidum
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Stratum granulosum
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Stratum germinativum – undergoes cell division and contains melanin (brown pigment)
●
Dermis
●
Subcutaneous Tissue
Nail and related structure
The nails, located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow
from the cuticle
✔
Hair – layers of keratinized cells found over the body
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Follicle - develop within a sheath of epidermal cells; hair growth occurs at the base of the hair follicle
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Shaft - Visible above the skin
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Root – surrounded by hair follicle
2 Types of Hair
✔
Vellus hair – (peach fuzz) short, pale, fine and seen over the body; thermoregulation by wicking sweat away from the
body
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Terminal hair – (particularly scalp and eyebrows) longer, darker and coarser.
Physical Assessment:
Integumentary: (SKIN, HAIR and NAIL)
Preparing the client for skin, hair, and nail examination,
✔
ask the client to: Remove all clothing and jewelry and put on an examination gown
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Remove nail enamel, artificial nails, wigs, hairpieces as appropriate
✔
Sit comfortably on the examination table or bed for the beginning of the examination Lie on her side or
abdomen to assess the skin on the buttocks and dorsal surfaces
Equipments:
•
Examination light
•
Penlight
•
Magnifying light
•
Centimeter ruler
•
Gloves
•
Wood’s light
•
Examination gown or drape
During the skin examination:
✔
Ensure privacy by exposing only the body part being examined Make sure that the room is a comfortable
temperature
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Explain what you are going to do, and answer any questions that client may have Wear gloves when
palpating because you may be exposed to drainage
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Consider the client’s culture when preparing for assessment
When preparing to examine the skin, hair, and nails remember these key points:
✔
Skin color, temperature, moisture, texture
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Skin integrity
✔
Skin lesions
✔
Capillary refill
Physical assessment procedure:
Skin (Inspection & Palpation)
✔
Inspect general skin color Inspect for color variations Inspect for lesions
✔
Palpate skin to assess texture
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Use palmar surface of your three middle fingers Palpate to assess thickness
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Put gloves on and palpate the lesions between the thumb and finger.
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Observe drainage or other characteristics
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Palpate to assess moisture
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Check under skin folds and in unexposed areas
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Palpate to assess temperature
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Use dorsal surfaces of your hands to palpate the skin
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Palpate to assess mobility and turgor
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Using two fingers, gently pinch the skin on the sternum or under the clavicle
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Palpate to detect edema
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Use thumb down on the skin of the feet or ankles
Skin Inspection
Normal:
✔
Evenly colored skin tone
Abnomal:
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Pallor Cyanosis
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Central cyanosis (oral mucosa)
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Peripheral cyanosis
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Jaundice
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Acanthosis Nigricans Pallor
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Jaundice Cyanosis
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Acanthosis Nigricans
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Pallor (LAPSI) (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia.
Cyanosis may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas.
Dark skin may appear blue, dull, and lifeless in the same areas.
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.
Acanthosis nigricans is roughening and darkening of skin in localized areas, especially the posterior neck
Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem
resulting from vasoconstriction.
Skin Color Variations
NORMAL
✔
Suntanned areas, freckles, white patches or Vitiligo Albinism
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Dark skinned - lighter colored palms, soles, nail beds, lips Freckle –like or dark streaks of pigmentation
ABNORMAL
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Rashes e.g reddish or darkened butterfly rash / “ malar” rash across the bridge of the nose and cheeks –
SLE
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Erythema
Skin Integrity
NORMAL
✔
Intact , no reddened area
ABNORMAL
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with skin breakdown, reddened area noted that may progress to serious and painful pressure ulcer
Lesions
NORMAL
✔
Smooth without lesions
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Stretch marks, healed scars, freckles, moles or birthmarks
ABNORMAL
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Primary lesion
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Secondary lesion
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Vascular lesions - reddish, bluish lesions
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Cancerous lesions
Primary Skin Lesion
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Macule & Patch
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Papule & Plaque
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Nodule & Tumor
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Vesicle & Bulla
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Wheal
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Patulle
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Cyst
MACULE AND PATCH
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Small, flat, non palpable skin color change (skin color may be brown, white, tan, purple, red).
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Macules are less than 1 cm with a circumscribed border, whereas patches are greater than 1 cm, and
may have an irregular border. Examples include freckles, flat moles, petechiae, rubella (pictured below),
vitiligo, port wine stains, and ecchymosis
VESICLE AND BULLA
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Circumscribed elevated, palpable mass containing serous fluid.
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Vesicles are less than 0.5 cm; bullas are greater than 0.5 cm. Examples of vesicles include herpes
simplex/zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn. Examples of
bulla include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.
PAPULE AND PLAQUE
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Elevated, palpable, solid mass. Papules have a circumscribed border and are less than 0.5 cm; plaques
are greater than 0.5 cm and may be coalesced papules with a flat top. Examples of papules include
elevated nevi, warts, and lichen planus. Examples of plaques include psoriasis (psoriasis vulgaris
pictured below) and actinic keratosis
PUSTULE
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Pus-filled vesicle or bulla. Examples include acne (pictured below), impetigo, furuncles, and carbuncles.
WHEAL
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Elevated mass with transient borders that are often irregular. Size and color vary. Caused by movement
of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Examples include
urticaria (hives, pictured below) and insect bites.
NODULE AND TUMOR
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Elevated, solid, palpable mass that extends deeper into dermis than a papule. Nodules are 0.5 to 2 cm
and circumscribed; tumors are greater than 1 to 2 cm and do not always have sharp borders. Examples
of nodules include keloid (pictured below), lipoma, SCC, poorly absorbed injection, and dermatofibroma.
Examples of tumors include larger lipoma and carcinoma.
CYST
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Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis.
Examples include sebaceous cyst and epidermoid cyst (pictured below).
Secondary Skin Lesion
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Erosion
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Scar
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Ulcer
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Fissure
Vascular Skin Lesions
Vascular skin lesions are associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic
disease, among other problems.
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Petechiae
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Ecchymosis
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Hematoma
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Cherry Angioma
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Spider Angioma
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Venous Star (Telangiectasis)
PETECHIA (PL. PETECHIAE)
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Round red or purple macule that is 1–2 mm in size. It is secondary to blood extravasation
TELANGIECTASIS (VENOUS STAR)
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Bluish or red lesion with varying shape (spider-like or linear) found on the legs and anterior chest. It does
not blanch when pressure is applied. It is secondary to superficial dilation of venous vessels and
capillaries and associated with increased venous pressure states (varicosities).
CHERRY ANGIOMA
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Papular and round, red or purple lesion found on the trunk or extremities. It may blanch with pressure. It
is a normal age-related skin alteration and usually not clinically significant.
PALPATE SKIN:
Texture - use palmar surface of 3 middle fingers to palpate skin texture
NORMAL:
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Skin is smooth and even
ABNORMAL:
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Rough, flaky dry skin – hypothyroidism
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Obese – dry, itchy skin
Thickness
NORMAL:
✔
Normally thin, but calluses (rough, thick sections of the epidermis) – exposed to constant pressure.
ABNORMAL:
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Very thin skin in arterial insufficiency or those in steroid therapy
Palpate to assess Temperature: use the dorsal surface to palpate for temperature
NORMAL:
✔
Warm temperature
ABNORMAL:
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Cold skin – accompany shock or hypotension
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Cool skin – arterial disease
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Very warm skin – febrile state or hyperthyroidism
Palpate to assess mobility and turgor - ask the client to lie down, gently pinch the skin over the clavicle.
Mobility – refers to how easily the skin can be pinched
Turgor – refers to skin elasticity and how quickly the skin returns to its original shape after being pinched
NORMAL:
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mobile, elastic and returns to original shape quickly; recoil is immediate
ABNORMAL:
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Decreased mobility – edema
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Decreased turgor – dehydration
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recoil in less than 2 sec – moderate dehydration
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recoil in more than 2 sec – severe dehydration
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More than 3 sec – is Tenting
Palpate to detect EDEMA
NORMAL:
✔
skin rebounds and does not remain indented when pressure is released
ABNORMAL:
✔
Indentations vary – maybe in one area or all over the body use thumb to press down on the feet, ankle,
pretibial
Scalp and Hair: (Inspection and Palpation)
Condition, cleanliness, texture: separate the hair at 1 inch interval and inspect and palpate the hair and scalp
for cleanliness, dryness, oiliness, parasites and lesions – wear gloves if with lesions or poor hygiene.
NORMAL:
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Natural hair color varies among clients e.g race
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The color is determined by the amount of melanin present Scalp is clean and dry, sparse dandruff may
be visible Hair is smooth, firm, somewhat elastic
ABNORMAL
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Patchy-gray hair in some area copper red hair color Excessive scaliness
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Raised lesion
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Dull dry hair
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Poor hygiene
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PUSTULES WITH HAIR LOSS IN PATCHES – TINEA CAPITIS – a contagious fungal disease
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Infection of hair follicle (folliculitis)
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Patchy gray hair
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Dermatitis
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Copper red hair
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Folliculitis
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Patchy Hair loss
Nails: (Inspection and Palpation)
Grooming,cleanliness, consistency:
NORMAL:
✔
Clean and manicured
ABNORMAL:
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Dirty, broken or jagged fingernails – poor hygiene or result of hobby or occupation
Color, markings
NORMAL:
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Pink tones, longitudinal ridging is normal
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Dark skinned client – freckles or pigmented streaks in the nails
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ABNORMAL:
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Pale or cyanotic – hypoxemia or anemia
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Splinter haemorrhage – trauma
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Beau lines
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Nail Pitting
SHAPE
NORMAL:
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160 degrees angle between the nail base and the skin
ABNORMAL:
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Early clubbing (180 degree angle with spongy sensation) and
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late clubbing ( > 180 degree) – Hypoxia
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Spoon nails (concave) – iron deficiency anemia
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Spoon nails
Texture
NORMAL:
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HARD AND IMMOBILE
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CULTURAL CONSIDERATION: Dark skinned – thicker nails
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OLDER ADULT: Thickened, yellow, brittle – decrease circulation in the extremities
ABNORMAL:
✔
Thickened nails especially toenails – decreased circulation and seen in ONCHOMYCOSIS – also known
as Tinea Unguium
Nail plate attachment to nail bed
NORMAL:
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smooth and firm, nail plate is firmly attached to nail bed
ABNORMAL
✔
Paronychia - Detachment of nail plate from nail bed; Inflammation indicates local infection
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Onycholysis – seen in infection or trauma
Capillary Refill: press the nail tip briefly and watch for color change
NORMAL:
✔
Pink tone returns immediately to blanched nails when pressure is released
ABNORMAL
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Slow > than 2 sec for clients with respiratory or cardiovascular disease - Hypoxia