HEALTH ASSESSMENT

Physical Assessment
of the Integument

Christine M. Fiel, RN MN LPT MAED

Topics to be Covered

a. Review of Anatomy and

Physiology
b. Collecting Subjective Data
c. Collecting Objective Data
d. Documentation
Structure and
Function
The skin, hair, and nails are external
structures that serve a variety of
specialized functions.
Skin
The skin is composed of three layers: the epidermis,
dermis, and subcutaneous tissue . The skin is thicker on DERMIS
the palms of the hands and soles of the feet and is • It is the inner layer of skin,
continuous with the mucous membranes at the orifices of • The dermis is a well-vascularized connective tissue layer
the body. Subcutaneous tissue, which contains varying containing collagen and elastic fibers, nerve endings, and lymph
amounts of fat, connects the skin to underlying structures. vessels.
• It is also the origin of hair follicles, sebaceous glands, and sweat
EPIDERMIS glands.
It is the outer layer of skin, is composed of four distinct layers:
▪ stratum corneum • SEBACEOUS GLANDS- sebum
▪ stratum lucidum • SWEAT GLANDS- eccrine (body), apocrine (armpit. genital areas)
▪ stratum granulosum
▪ stratum germinativum
SUBCUTANEOUS TISSUE
▪ This layer almost completely replaced every 3 to 4 weeks.
• containing fat cells, blood vessels, nerves, and the remaining
portions of sweat glands and hair follicles
▪ stratum germinativum is the only layer that undergoes cell division
• assists with heat regulation and contains the vascular pathways for
and contains melanin (brown pigment) and keratin-forming cells.
the supply of nutrients and removal of waste products from the
▪ Skin color depends on the amount of melanin and carotene (yellow
skin
pigment) contained in the skin and the volume of blood containing
hemoglobin, the oxygen-binding pigment that circulates in the dermis.
 Functions of Integumentary System

Protection
Sensation
Vitamin D production
Temperature Regulation
Excretion
DID YOU KNOW?
Digital health industry funding
• An adult skin covers an average of
3,000 square inches of surface area
$11.5B
(almost 2m)
• Adult skin weighs an average of
2.7kg (6lbs)
• The skin receives approximately 1/3
of the circulating blood in the body
• It is flexible, able to repair itself
• almost waterproof
Hair
Hair consists of layers of keratinized cells and is found
over much of the body except for the lips, nipples, soles of
the feet, palms of the hands, labia minora, and penis.

VELLUS HAIR
short, pale, and fine and is present over much of the body

TERMINAL HAIR
(particularly scalp and eyebrows) is longer, generally darker, and
coarser than the vellus hair

Hair serves useful functions.

Scalp hair is a protective covering.

Nasal hair and ear hair, as well as eyelashes and

eyebrows, filter dust and other airborne debris.
 NAILS
• located on the distal phalanges of fingers and
toes

• It protects the distal ends of the fingers and

toes.

• are hard, transparent plates of keratinized

epidermal cells that grow from a root
underneath the skin fold called the cuticle

• The nail body extends over the entire nailbed

and has a pink tinge as a result of the rich blood
supply underneath.

• At the base of the nail is the lunula, a paler,

crescent-shaped area.
 HEALTH ASSESSMENT:

COLLECTING SUBJECTIVE DATA:

THE NURSING HEALTH HISTORY

• Gathered subjective data provides focus on your physical assessment.

• Having a complete and accurate history taking enhances the collection of
objective data.
Collecting Subjective Data
• To perform a complete and accurate assessment, the nurse needs to collect data about current
symptoms, the client’s past and family history, and lifestyle and health practices.

• The information obtained provides clues to the client’s overall level of functioning in relation to the
skin, hair, and nails.

• Keep in mind that a nonjudgmental and sensitive

approach is needed if the client has abnormalities that
may be associated with poor hygiene or unhealthful
behaviors.
• Also, some skin disorders might be highly visible and
potentially damaging to the person’s body image and
self-concept.
HEALTH ASSESSMENT:

COLLECTING OBJECTIVE DATA:

PHYSICAL ASSESSMENT
Physical assessment of the skin, hair, and
nails provides the nurse with data that may
reveal local or systemic problems or
alterations in a client’s self-care activities.

A separate, comprehensive skin, hair, and

nail examination, preferably at the beginning
of a comprehensive physical examination,
ensures that you do not inadvertently omit
part of the examination.
Preparing the Client
1. Ask the client to remove all clothing and jewelry and put on an examination gown.
2. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces
as appropriate.
3. Have the client sit comfortably on the examination table or bed for the beginning of the
examination.
4. The client may remain in a sitting position for most of the examination. However, to assess
the skin on the buttocks and dorsal surfaces of the legs properly, the client may lie on her
side or abdomen.
5. Ensure privacy by exposing, only the body part being examined should be exposed.
6. Make sure that the room is at a comfortable temperature.
7. If available, sunlight is best for inspecting the skin. However, a bright light that can be
focused on the client works just as well.
8. Keep the room door closed or the bed curtain drawn to provide privacy as necessary.
9. Explain what you are going to do, and answer any questions the client may have.
10.Wear gloves when palpating any lesions because you may be exposed to drainage.

Clients from conservative religious groups may require that the nurse be the same
sex as the client. Also, to respect the client’s modesty or desire for privacy, provide a
long examination gown or robe.
 Equipment

• Examination light
• Penlight
• Mirror for client’s self-examination
of skin
• Magnifying glass
• Centimeter ruler
• Gloves
• Wood’s light • Braden Scale for Predicting Pressure Sore Risk
• Examination gown or drape • Pressure Ulcer Scale for Healing (PUSH) tool to
measure pressure ulcer healing
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.
SKIN ASSESSMENT:

INSPECTION AND PALPATION

 Inspection
Inspect for general discoloration.

NORMAL FINDINGS
• Inspection reveals evenly colored
skin tones without unusual or
prominent discolorations.
• Small amounts of melanin are
common in whiter skins, while large
amounts of melanin are common in
olive and darker skins.
• Carotene accounts for a yellow cast.
• The older client’s skin becomes pale
due to decreased melanin production
and decreased dermal vascularity
 ABNORMAL FINDINGS
Inspection • Pallor
• Cyanosis
Inspect for general discoloration. • Jaundice
• Acanthosis Nigricans
 Inspection
While inspecting skin coloration, note
any odors emanating from the skin.

NORMAL FINDINGS
• Client has slight or no odor of perspiration,
depending on activity

ABNORMAL FINDINGS
• A strong odor of perspiration or foul odor may
indicate disorder of sweat glands.
• Poor hygiene practices may indicate a need for
client teaching or assistance with activities of
daily living.
 Inspection
Inspect for color variations. Inspect localized parts of
the body, noting any color variation.

NORMAL FINDINGS suntanned

• Keep in mind that some clients have
suntanned areas, freckles, or white patches
known as vitiligo
vitiligo
• The variations are due to different amounts of
melanin in certain areas.
• Dark-skinned clients have lighter-colored
palms, soles, nailbeds, and lips.
• Frecklelike or dark streaks of pigmentation are
also common in the sclera and nailbeds of
dark-skinned clients. freckles
 Inspection
Inspect for color variations. Inspect localized parts of
the body, noting any color variation.

ABNORMAL FINDINGS
• rashes
• albinism
• erythema rashes

albinism

erythema
 Inspection
Check skin integrity, especially carefully
in pressure point areas.

NORMAL FINDINGS
• Skin is intact, and there are no
reddened areas.

ABNORMAL FINDINGS
• Skin breakdown is initially noted as a reddened area
on the skin that may progress to serious and painful
pressure.
• Depending on the color of the client’s skin, reddened
areas may not be prominent, although the skin may
feel warmer in the area of breakdown than elsewhere.
Stages of ulcer
 Inspection NORMAL FINDINGS
• Inspect for lesions. • Smooth, without lesions. Stretch
• Observe the skin surface to detect marks (striae), healed scars,
abnormalities. freckles, moles, or birthmarks
• Note color, shape, and size of lesion. are common findings.
• For very small lesions, use a magnifying glass
to note these characteristics.

ABNORMAL FINDINGS
Primary lesions arise from normal skin due to irritation or disease.
Secondary lesions arise from changes in primary lesions.
Vascular lesions, reddish-bluish lesions, are seen with bleeding, venous pressure, aging, liver
disease, or pregnancy.
Skin cancer lesions can be either primary or secondary lesions and are classified as squamous
cell carcinoma, basal cell carcinoma, or malignant melanoma
Cherry Angioma
Palpation
Palpates skin to assess texture.
Uses palmar surface of three
middle fingers to palpate skin
texture.

NORMAL FINDINGS
• Skin is smooth and even.

ABNORMAL FINDINGS
• Rough, flaky, dry skin is seen in hypothyroidism.
• Obese clients often report dry, itchy skin.
 Palpation
Palpate to assess thickness.
Puts gloves on and palpates the lesion
between the thumb and index finger for size,
mobility, consistency, and tenderness if
lesions are noted when assessing skin
thickness. Observes for drainage or other
characteristics. NORMAL FINDINGS
Skin is normally thin but calluses (rough,
thick sections of epidermis) are common
ABNORMAL FINDINGS
on areas of the body that are exposed to
• Very thin skin may be seen in constant pressure.
clients with arterial insufficiency
or in those on steroid therapy.
 Palpation NORMAL FINDINGS
Palpates to assess moisture. Skin surfaces vary from moist to dry
Checks under skin folds and in depending on the area assessed. Recent
unexposed areas. activity or a warm environment may
cause increased moisture.

ABNORMAL FINDINGS
Increased moisture or diaphoresis (profuse
sweating) may occur in conditions such as
fever or hyperthyroidism. Decreased moisture
occurs with dehydration or hypothyroidism.

Clammy skin is typical in shock or

hypotension.
Palpation
Palpates to assess temperature.
Uses the dorsal surfaces of hands
to palpate the skin.

NORMAL FINDINGS
Skin is normally a warm temperature.

ABNORMAL FINDINGS
• Cold skin may accompany shock or hypotension.
• Cool skin may accompany arterial disease.
• Very warm skin may indicate a febrile state or
hyperthyroidism.
Palpation
Palpates to assess mobility and turgor.
Asks the client to lie down. Using two
fingers, gently pinches the skin over
the clavicle. Checks skin mobility and
turgor.
NORMAL FINDINGS
Normally, the skin is mobile, with
elasticity and returns to original shape
quickly. ABNORMAL FINDINGS
• Decreased mobility is seen with edema.
• Decreased turgor (a slow return of the skin to
its normal state taking longer than 30 seconds)
is seen in dehydration.
Palpation
Palpates to detect edema. Uses
thumbs to press down on the skin of
the feet or ankles to check for edema.

NORMAL FINDINGS
Skin rebounds and does not remain
indented when pressure is released.

ABNORMAL FINDINGS
Indentations on the skin may vary from
slight to great and may be in one area or
all over the body.
Carbuncle vs Furuncle
SCALP AND HAIR ASSESSMENT:

INSPECTION AND PALPATION

Inspection
Have the client remove any hair clips, hair pins, or wigs. Then
inspect the scalp and hair for general color and condition.

NORMAL FINDINGS
Natural hair color, as opposed to
chemically colored hair, varies among
clients from pale blond to black to gray or
white. The color is determined by the
amount of melanin present.

ABNORMAL FINDINGS
Nutritional deficiencies may cause patchy gray hair in
some clients.
Severe malnutrition in African American children may
cause a copper red hair color.
Inspection
At 1-inch intervals, separate the hair from the scalp and
inspects and palpates the hair and scalp for cleanliness,
dryness, or oiliness, parasites, and lesions. Wear gloves
if lesions are suspected or if hygiene if poor.

NORMAL FINDINGS
Scalp is clean and dry. Sparse dandruff may be
visible. Hair is smooth and firm, somewhat
elastic.

ABNORMAL FINDINGS Poor hygiene may indicate a need for client teaching or
assistance with activities of daily living.
Excessive scaliness may indicate dermatitis.
Pustules with hair loss in patches are seen in tinea capitis, a
Raised lesions may indicate infections or tumor growth.
contagious fungal disease.
Dull, dry hair may be seen with hypothyroidism and
Infections of the hair follicle (folliculitis) appear as pustules
malnutrition.
surrounded by erythema.
Inspection NORMAL FINDINGS
Varying amounts of terminal hair cover the
Inspect amount and distribution of scalp, body,
axillae, and pubic hair. Looks for unusual growth scalp, axillary, body, and pubic areas according
elsewhere on the body. to normal gender distribution. Fine vellus hair
covers the entire body except for the soles,
palms, lips, and nipples. Normal male pattern
ABNORMAL FINDINGS balding is symmetric.
Excessive generalized hair loss may occur with
infection, nutritional deficiencies, hormonal disorders,
thyroid or liver disease, drug toxicity, hepatic or renal
failure.
.
Patchy hair loss may result from infections of the scalp,
discoid or systemic lupus erythematosus, and some
types of chemotherapy.
Hirsutism (facial hair on females) is a characteristic of
Cushing’s disease and results from an imbalance of
adrenal hormones or it may be a side effect of steroids.
Inspection
Inspect nail grooming and cleanliness.

NORMAL FINDINGS
Nails are clean and manicured.

ABNORMAL FINDINGS

Dirty, broken, or jagged fingernails may be

seen with poor hygiene. They may also
result from the client’s hobby or
occupation.
.
 ABNORMAL FINDINGS
Inspection Pale or cyanotic nails may indicate hypoxia
Inspect nail color and markings. or anemia. Splinter hemorrhages may be
NORMAL FINDINGS caused by trauma.
Pink tones should be seen. Some Beau’s lines occur after acute illness and
longitudinal ridging is normal. eventually grow out.
Dark-skinned clients may have freckles or Yellow discoloration may be seen in fungal
pigmented streaks in their nails. infections or psoriasis. Nail pitting is also
common in psoriasis.
.

Beau’s lines
Inspection
Inspect shape of nails.

NORMAL FINDINGS
There is normally a 160-degree angle
between the nail base and the skin.

ABNORMAL FINDINGS

Early clubbing (180-degree angle with

spongy sensation) and late clubbing
(greater than 180-degree angle) can occur
from hypoxia.
Spoon nails (concave) may be present with
iron deficiency anemia. Beau’s lines
Palpation
Palpate nail to assess texture.
NORMAL FINDINGS
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.

ABNORMAL FINDINGS

Thickened nails (especially toenails) may

be caused by decreased circulation, and Beau’s
is lines
also seen in onychomycosis.
Palpation
Palpate to assess texture and
consistency, noting whether nailplate
is attached to nailbed.

NORMAL FINDINGS
Nails are smooth and firm; nailplate
should be firmly attached to nailbed.

ABNORMAL FINDINGS

Paronychia (inflammation) indicates local

infection. Detachment of nailplate from
nailbed (onycholysis) is seen in infections
or trauma.
Palpation
Test capillary refill in nailbeds by
pressing the nail tip briefly and
watching for color change.

NORMAL FINDINGS
Pink tone returns immediately to
blanched nailbeds when pressure is
released.
ABNORMAL FINDINGS

There is slow (greater than 2 seconds)

capillary nailbed refill (return of pink tone)
with respiratory or cardiovascular diseases
that cause hypoxia.
Palpation
Test capillary refill in nailbeds by
pressing the nail tip briefly and
watching for color change.

NORMAL FINDINGS
Pink tone returns immediately to
blanched nailbeds when pressure is
released.
ABNORMAL FINDINGS

There is slow (greater than 2 seconds)

capillary nailbed refill (return of pink tone)
with respiratory or cardiovascular diseases
that cause hypoxia.
 Validating and Documenting Findings

Validate your Document the Abnormal findings

normal and skin, hair, and nail would be carefully
abnormal findings assessment data documented too.
with the client, that you have Normal findings can
other health care collected on the act as a baseline for
workers, or your appropriate form findings that may
instructors. your school or change later.
agency uses.
Thank You!
Do you have any questions