Guided Lecture Notes
Chapter 14: Assessing Skin, Hair, and Nails
Learning Objective # 1. Describe the structures and functions of the skin, nail and hair.

Explain the structure and function of epidermis, dermis and subcutaneous tissue
of the skin. (Refer to Figure14.1 and PowerPoint slides 02 - 07)
o The skin is a physical barrier that protects the underlying tissues and
structures from microorganisms, physical trauma, ultraviolet radiation, and
dehydration.
o Vital role in temperature maintenance, fluid and electrolyte balance,
absorption, excretion, sensation, immunity, and vitamin D synthesis.

Explain the structure of vellus and terminal hair. (Refer to Figure14.1)

Describe the structure of nail. (Refer to Figure14.2)
Learning Objective # 2. Discuss risk factors for skin cancer and METHICILLINRESISTANT STAPHYLOCOCCUS AUREUS across
cultures and ways to reduce one’s risks.
Discuss the risk factors associated with skin cancer. (Refer to Abnormal
Findings 14.5 and PowerPoint slides 8-10)
o Sun exposure
o Nonsolar sources of ultraviolet radiation
o Medical therapies
o Family history and genetic susceptibility
o Moles
o Pigmentation irregularities
o Fair skin that burns and freckles easily; light hair
o Age
o Male gender
o Chemical exposure
o Human papillomavirus
o Xerodrem pigmentosum
o Long-term skin inflammation or injury
o Alcohol intake; smoking
o Inadequate niacin in diet

Discuss the measures to reduce the risk factors for skin cancer. (Refer to
PowerPoint slides 11- 14)
o Reduce skin exposure
o Always use sunscreen when sun exposure is anticipated
o Wear long-sleeve shirts and wide-brimmed hats
o Avoid sunburns
o Understand the link between sun exposure and skin cancer and the
accumulating effects of sun exposure on developing cancers
o Have annual skin cancer screenings
o Ensure diet is adequate in vitamin B3
o Examine the skin for suspected lesions
1.
2.
3.
4.
5.
6.
Use the ABCDE mnemonic to assess suspicious lesions:
Asymmetry
Border
Color
Diameter
Elevation

Describe the variations in prevalence of skin color across cultures. (Refer to
PowerPoint slide 15)
o Lowest rates: Asians
o Highest rates: white Australians
o Most susceptible are people with pale white, freckled skin and red hair

Discuss the risk factors associated with METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS.
(Refer to Evidence Based Health Promotion and
Disease Prevention 14.1and PowerPoint slides 16 - 18)
o Assess for hospital-acquired MRSA risk factors:
1. Having an invasive medical device
2. Residing in a long-term care facility
o Assess for community-acquired MRSA risk factors:
1. Participating in contact sports
2. Sharing personal items such as towels or razors
3. Suppression of the immune system function (e.g. HIV, cancer, or
chemotherapy)
4. Residing in unsanitary or crowded living conditions (dormitories
or military barracks)
5. Working in the health-care industry
6. Receiving antibiotics within the past 3 to 6 months
7. Young or advanced age
8. Men having sex with men

Discuss the measures to reduce the risk factors for METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS.
(Refer to PowerPoint slide 19)
o Keep wounds covered.
o Do not share personal items.
o Avoid unsanitary or unsafe nail care practices.
o If treatment has been started, do not stop until recovery is complete.
o Use universal precautions when touching others to avoid contact with
contaminated body fluids. Wash your hands.
o Clean sports equipment between uses to avoid spread of infection.
o
Learning Objective # 3. Interview a client for an accurate nursing history of the skin,
nails and hair.

Review collecting subjective data for an accurate nursing history of the skin,
nails, and hair

History of present health concern (Refer to PowerPoint slide 20)

Body odor problems

Skin problems (rashes, lesions, dryness, oiliness,
drainage, bruising, swelling, pigmentation)

Changes in lesion appearance

Feeling changes (pain, pressure, itch, tingling)

Hair loss or changes

Nail changes

Personal health history

Family history

Lifestyle and health practices
1. Exposure to sun or chemicals
2. Daily care of skin, hairs, nails
3. Usual diet and exercise patterns (Refer to PowerPoint slide 21)
Learning Objective # 4. Perform a physical assessment of the skin, nails, and hair using
the correct techniques.

Describe the preparation of the client for assessment of skin, hair and nails. (Refer
to PowerPoint slide 22)
o Ask the client to remove all clothing and jewelry
o Have the client sit comfortably
o Ensure privacy
o Maintain comfortable room temperature

List the equipment necessary for performing a skin, hair, and nail assessment.
(Refer to PowerPoint slide 23)
o Gloves
o Examination light and penlight
o Magnifying glass
o Centimeter ruler
o Wood’s light
o Examination gown or drape
o Assessment Tool 14.1. Braden Scale For Predicting Pressure Sore Risk
o Assessment Tool 14.2. PUSH Scale to Measure Pressure Ulcer Healing

Describe the inspection assessments of skin (Refer to PowerPoint slide 24)
o Note any distinctive odor
o Generalized color variations (brownness, yellow, redness, pallor, cyanosis,
jaundice, erythema, vitiligo)
o Skin breakdown
o Primary, secondary, or vascular lesions (note size, shape, location,
distribution and configuration). Use Wood’s lamp if fungus is suspected.
1. Primary: arise from normal skin due to irritation or disease
2. Secondary: arise from changes in primary lesions
3. Vascular: reddish-blue lesions are seen with bleeding, venous
pressure, aging, liver disease, or pregnancy.

Describe the palpation assessments of skin (Refer to PowerPoint slide 25):
o Lesions
o Texture (rough or smooth) using palmar surface of three middle fingers
o Temperature (cool, warm, hot) and moisture (dry, sweaty, oily) using
dorsal side of hand
o Thickness of skin with finger pads
o Mobility and turgor by pinching up skin over sternum
o Edema by pressing thumb over feet or ankles

Describe the stages of pressure ulcers including risk factors and ways to reduce
these risk factors. (Refer to Abnormal Findings 14.1, Pressure Ulcer Stage, and
PowerPoint slides 26-28)
o Risk Factors
 Perception: inability to perceive pressure
 Mobility: inability to move self; decreased activity level; unable to
reposition
 Moisture: diaphoresis; incontinences; sweating from climate
 Nutrition: deficient (especially protein deficit) or excessive (obesity)
 Friction or shear against surfaces
 Tissue tolerance decreased: age; vascular incompetence; blood sugar
levels of diabetes mellitus; body weight/malnutrition
o Risk Reduction Tips
 Inspect the skin at least daily and more often if at greater risk using
risk assessment tool (such as Braden Scale or PUSH tool) and keep
flow chart to document.
 Bathe with mild soap or other agent; limit friction; use warm not hot
water; set bath schedule that is individualized.
 For dry skin: use moisturizers; avoid low humidity and cold air.
 Avoid vigorous massage.
 Use careful positioning, turning, and transferring techniques to avoid
shear and friction or prolonged pressure on any point.
 Refer nutritional supplementation needs to primary care provider or
dietitian, especially if protein deficient.
 Refer incontinence condition to primary care provider.
 Use incontinence skin cleansing methods as needed: frequency and
methods of cleaning, avoiding dryness with protective barrier
products.

Describe the assessment of scalp and hair for color, cleanliness, dryness or
oiliness, parasites, and lesions. (Refer to PowerPoint slide 29)

Explain the assessment of nails for grooming, color, markings, shape, texture,
consistency. (Refer to PowerPoint slide 30)

List the types of nail abnormalities including risk factors and ways to reduce these
risk factors.
o Risk Factors (Refer to PowerPoint slide 31)
 Nails in moist environment, especially walking in damp public locales
(swimming pools, showers) or continuously wearing closed shoes;
excessive perspiration.
 Nail injury, trauma, or irritation (tight footwear, exercise trauma,
artificial nails, excessive hand washing, nail biting).






Repeated irritation (especially water, detergents).
Immune system disorders such as diabetes mellitus and AIDS or on
immunosuppressive medications.
Skin conditions such as psoriasis or lichen.
Some trades or professions (damp environments or shoe type
required).
Contagion from one digit to another or one person to another.
Possibly family predisposition.
Risk Reduction Tips (Refer to PowerPoint slide 32)
 Wear leather shoes except for sports.
 Avoid wearing closed shoes all the time.
 Wear socks that wick away moisture.
 Avoid going barefoot in damp public areas.
 Avoid too much perspiration or water (wear gloves for hands).
 Avoid trauma to nails.
 Avoid unsanitary or unsafe nail care practices
 If treatment is started, do not stop until recovery is complete.

Describe the procedure to assess capillary refill. (Refer to Figure 14.15 and
Power Point slide 33))

Discuss the differences in hair color and texture seen in ethnic groups. (Refer to
PowerPoint slide 33)
o Individuals of black American descent often have very dry scalps and dry,
fragile hair.
Learning Objective # 5. Teach a client how to perform a self-assessment of the skin,
hair and nails.

Review Box 14-1 Self Assessment: How to Examine Your Own Skin (Refer to
Box 14.1 Self Assessment: How to Examine Your own Skin and Power Point
Slide 34)
Learning Objective # 6. Differentiate between normal and abnormal findings of the
skin, hair and nails

Review and discuss findings of client’s skin, hair and mails assessment with class
peers (Refer to PowerPoint slide 35)

Pressure Ulcer Stage (Refer to Abnormal Findings 14.1: Pressure Ulcer Stage
and PowerPoint slide 36)
o Stage One
o Stage Two
o Stage Three
o Stage Four
o Unstagable

Primary Skin Lesions (Refer to Abnormal Findings 14-2: Primary Skin Lesions
and PowerPoint slide 37)
o Macule and Patch
o Papule and Plaque
o Nodule and Tumor
o Vesicle and Bulla
o Wheal
o Pustule
o Cyst

Secondary Skin Lesion (Refer to Abnormal Findings 14-3: Secondary Skin
Lesions abd PowerPoint slide 38)
o Erosion
o Ulcer
o Sacr
o Fissure

Vascular Skin Lesions (Refer to Abnormal Findings 14-4: Vascular Skin Lesions
and Power Point slide 39)
o Petechia
o Ecchymosis
o Hematoma
o Cherry Angioma
o Spider Angioma
o Telangiectasis

Common Nail Disorder (Refer to Abnormal Findings 14-7: Common Nail
Disorders and Power Point slide 40)
o Longitudinal ridging
o Half and half nails
o Pitting
o Koilonychia
o Yellow nail syndrome
o Paronychia
Learning Objective # 7. Describe findings frequently seen when assessing the older
client’s skin, hair, and nails.

Discuss the differences in skin, hair and nail characteristics of elderly people.
(Refer to PowerPoint slide 41)
o Skin

Pale

Skin lesions

Dry

Loses turgor
o Hair: Thinner
o Nails: Thickened, yellow, brittle
Learning Objective # 8. Analyze data from the interview and physical assessment of
the skin, hair and nails to formulate valid nursing diagnoses, collaborative problems,
and/or referrals.

Discuss as a group the data obtained of a client’s general survey and vital signs
risk to formulate valid nursing diagnoses, collaborative problems and/or referrals.
(Refer to PowerPoint slide 42)
