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Skin, Hair, and Nails Assessment
92 Plays11 months ago
In this episode we cover what an assessment of the skin, hair and nails looks like. We also cover some frequently confused terms related to describing abnormalities, and what documentation may look like for a completely normal assessment. If you have feedback for me please feel free to reach out to me by email at jaxon.jorgensen@gmail.com.
References:
Dains, J., Baumann, L., & Scheibel, P. (2024). Advanced health assessment and clinical diagnosis in primary care (7th ed.). Elsevier.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2024). Bates’ Guide to Physical Examination and history taking. Wolters Kluwer.
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Transcript
Introduction to Health Assessment Podcast
00:00:00
shermanappel
Hello valued listeners and welcome to the show. My name is Jackson Jorgensen. I'm going to be your host. This is episode two of my advanced practice nursing mastery podcast. ah The goal of this podcast is to help myself and graduate students to better understand the material related to health assessment and promotion. So we're going to dive right into it. This episode is going to be covering the assessment of hair, skin and nails. Um, and we'll talk about a couple of important things not to miss. We'll talk about some terminology. in both the hair and nails and skin department that I think are not commonly understood well. And we'll talk about documentation and why that's so important. So if you're studying that stuff right now, hopefully this podcast is useful to you.
Head-to-Toe Assessment Approach
00:00:44
shermanappel
Kicking it off, your hair, nails, and skin assessment is going to be a problems-focused assessment. So when I say that, I mean you're going to be looking for the abnormalities, and you're going to parse it out.
00:00:55
shermanappel
um It's going to be head to toe, so you're going to want to start at the top of their head body. You're going to begin with assessing their hair and their skin at the same time, so the scalp and hair. And you're just going to work your way down, make sure not to miss any spots, really common spots to miss lesions that could be important or the tops of the ears and the scalp, especially if they have any balding. There's both areas with high sun exposure with potential that you could miss a lesion that may be important. um You're also going to discuss this skin of their face um moving down to their shoulders.
00:01:29
shermanappel
And as you go moving down, you're going to be noting the color, temperature, and moisture of their skin. While you're assessing their hair, you're going to assess the thickness and the distribution and the color of their hair. um By distribution, is it evenly distributed? Is it ah sparse? um Are there random spots of balding? And these are all things you want to be thinking about. And you also want to apply that same logic for hair assessment to body hair. So make sure that you're thinking about that as you go through your assessment. um And it's best to just do all three of these assessments at the same time, because you're going to need to ah address each of the problems as they come up, but also you you're going from the top to the bottom, so you might as well hit each of these areas as you're going.
Torso and Hands Examination
00:02:12
shermanappel
um Moving down after you've assessed the the shoulders, you can move on to the arms and the torso. um Once you've gotten to the torso, it is important that you have the patient remove and replace clothing as necessary for this assessment.
00:02:25
shermanappel
um There's plenty of areas on the torso, especially the backs of the shoulders, upper and lower back um that are very prone for the patient to not be able to see. And so you have to make sure that you're performing an adequate assessment on those areas. But once you're finished with assessing those areas, you can gladly have the patient replace their clothing so that they can maintain some modesty throughout the assessment and feel comfortable. um After you've assessed the torso and the arms, you can ah look at the hands. You're going to want to look at both the palms and the backs of the hands. While you're assessing the hands, you can look at the nails. You're going to be wanting to note any changes in color, shape, or condition on those nails.
00:03:04
shermanappel
um Moving from the hands, you can go now from ah the torso to the lower body so you can ah ask the patient to remove ah their drawers so you can take a look at their bottom and ah inner thighs and make sure that you're not missing any of the skin on those areas as they are also often missed ah for the patient themselves. so um work your way down towards the feet. ah Once you've gotten to the feet and lower legs, then you're pretty much almost done with your assessment. The only thing you would have left then would be the soles of the feet, which is an important one not to miss, especially for your diabetic patients who may have injuries that they're not aware of on their feet. um And then you can do the nails, the toenails. And you're going to be looking for the same stuff on the toenails as you are on the fingernails, you know, the shape, color, condition,
00:03:54
shermanappel
ah and any damage that you might see. So now we've walked through what the assessment looks like from head
Key Questions for Skin Rashes
00:04:02
shermanappel
to tail. We're going to talk about a few things that you want to make sure to ask your patient. There's a few don't miss it questions related to two rashes. So if the patient comes in with a complaint of a rash, you want to make sure that you ask if they've had any fever or chills, shortness of breath, difficulty swallowing, if the rash is very, very tender, um or if there's mucus membrane involvement. All of those questions are important to ask because a positive answer to them
00:04:28
shermanappel
could indicate some underlying infection or other serious pathology that needs to be addressed a little bit more emergently. um
00:04:40
shermanappel
Continuing with this theme of a patient that has come in with a rash after you've asked those questions, you want to make sure that you review their history. um you know What have they been up to? You want to investigate what possible causes there are for this rash. um And also for any skin abnormalities in general, you want to make sure that for any abnormal findings that you're considering their family history, their own history, if they've had a history of malignant lesions, and you're going to want to make sure that you think about it from every
Factors in Skin Abnormalities Assessment
00:05:08
shermanappel
possible angle. you know Do they they use tanning beds frequently? Have they had a history of many sunburns that have flistered? Do they have a family history of skin cancer?
00:05:18
shermanappel
ah You want to be thinking about those things as well as ah any environmental exposures that they may have had over the past little while. um For example, poison ivy is a very common one that will cause a really nasty rash. um Any allergies that they might have that could be explaining the rash. um you know if they have If it's allergy season, you know that early spring when there's so much pollen in the air and their eyes are all puffy and their face is red, ah the the pollens could explain that rash and you can advise the patient that you know washing their pillowcases more often and doing a good facial wash before bed can help remove those allergens so and hopefully resolve their issue. so
00:06:01
shermanappel
um really think about these things from outside of the box. It's not necessarily always going to be something wrong with the body. It could be something that has they've ah contacted outside of it. On that trope, also consider what their skin care routine is.
Terminology for Skin Lesions
00:06:15
shermanappel
There's plenty of chemicals and soaps and shampoos that some patients might be sensitive to, so they should ah consider those things as well during your assessment. um Now, with that rash, you need to be able to describe this rash when you're documenting. ah So there's plenty of words that are used to describe these abnormal findings. What we would call it is a lesion case. So within the rash, there is lesions usually. um It could just be an erythematous rash where it's just red skin. And in that case, there's maybe not really lesions associated with it, but often um when a patient comes in with a rash, there will be associated lesions or abnormalities in the skin.
00:06:57
shermanappel
So there's two types of lesions. There's primary lesions and there's secondary lesions. A primary lesion is what we think of as like the initial abnormal finding and a secondary lesion is a result of patient activity towards that primary lesion. So for example, with chicken pox, those pox are quite itchy. If the patient is scratching at them and it causes damage to the skin or it causes the fluids to burst from those lesions and they start crusting up, then that's going to be secondary. um This is what I wanted to get into some of that terminology that we use to describe lesions and rashes. So I'm using ah two textbooks right now for guiding this podcast. I have Bates' Guide to Physical Examination and History-Taking and the Advanced Health Assessment and Clinical Diagnosis in Primary Care books, and I'll include ah citations for those in the show notes. so But in the health assessment book, there is a
00:07:57
shermanappel
plethora of terms used to describe lesions. um And if you're going into dermatology, you really probably ought to know them, but it is good for the primary care provider to know these terms because you are going to be referring your patients to dermatologists um as necessary and providing them with an adequate description of what you've seen can help prepare them in their clinic.
Dermatology Terms and Differences
00:08:19
shermanappel
Um, so the words that I feel like we should cover are macule, vesicle, bulla, pustule, uh, papule, nodule, patch and plaque and wheel. Those are all the primary lesion terminology terms that I thought would be useful to cover. And we're also going to cover a crust and scale and what the difference is between those. And then my kenification, which is a new word to me that I had to go ahead and look up and research a little bit more.
00:08:48
shermanappel
So starting off, macule, when you think macule, the other term that I often confuse it with is papule. The difference between the two, a macule is not palpable. If you were to run your hand over the patient's skin, you would not feel a macule. Think freckles, think ah changes in color, okay? So it's a discrete flat change, and ah that macule is usually going to be less than 1.5 centimeters in diameter. from macule, there is a larger version of it, which is a patch. So if you hear the word patch, we were talking about a macule that is larger than 1.5 centimeters in diameter. Okay, so then papule, and this is where we are going to start ah differentiating between similar sounding things. So a papule
00:09:41
shermanappel
and a nodule are both very similar, but the difference the key difference is size and ah possibly origin in some cases. So a papule is a discrete palpable elevation of skin. It's less than one centimeter in diameter. A good example of this would be a mole or a nevus. And then a nodule is also a palpable elevation of the skin. ah It may evolve from a papule, and it's usually going to be larger than that one centimeter diameter. um And moles are also an example of this if you have a large mole. If the mole is that size, you would actually be considering whether or not it is ah malignant for sure. um and Just to review, I'm sure you guys have heard the ABCDE acronym for remembering how to assess lesions for possible malignancy, but ah we will ah we'll go ahead and repeat those here. It's worth repeating, and especially if it is something that helps you catch a casein melanoma and and potentially protect one of your patient's
ABCDE Protocol for Skin Lesions
00:10:35
shermanappel
lives. so
00:10:36
shermanappel
ah The ABCD protocol when you're assessing papules or nodules, or nevi specifically, is you're looking for asymmetry, you're looking for irregular borders, you're looking for variations in color, you're looking for a diameter greater than 6 millimeters, and you're looking for evolution, meaning like change in the size or symptoms related to that nevis. So if you get a yes check mark on any of those questions, ah you want to give a little bit closer assessment and possibly consider um sending out for a referral to a dermatologist so that they can perform some other tests and exams and consider whether or not it needs to be removed.
Understanding Fluid-Filled Lesions
00:11:17
shermanappel
um Now that we've talked about papules and nodules, the next differentiation I wanted to go through was vesicle versus bulla versus pustule. So the pustule and the vesicle are both similar in size. The key difference is what kind of fluid they contain. So these are both raised lesions. You can fill them if you run your hand over them. ah You'll see that it's raised from the rest of the skin. and It may be red or inflamed, ah but the the key differentiation between a pustule and a vesicle is the color of fluid it contains. So a pustule contains yellow cloudy fluid. Think pus, similar to what you might have had in acne as a teenager.
00:11:54
shermanappel
ah that would be a pustule. A vesicle, same size, is going to be containing clear fluid. So think of the drainage from herpes simplex virus ah sores. Those sores are vesicles. And then a bula is just a large vesicle. So if the vesicle measures greater than 0.5 centimeters in diameter, it would be considered a bula. um And the adjective for that is bullus. So ah when you're describing it in documentation, you could describe the rash as bullus, or vesicular, or pustular, or papular, or maculopapular. All these terms we can apply to the lesions that we find in our rashes to help give a better description to what it is. Let's see, after the vesicle bullopustule, I wanted to talk about what a whale is. So a whale is a transient pink or red
00:12:48
shermanappel
swelling on the skin. i Think like a welt. um if you've ever ah This happens all the time in boys' locker rooms, or at least it did ah for me growing up. and that's You get the towel a little bit wet, wind it up, and you snap it at the guy next to you. It gives it a nice little welt. That would be a good example of a wheel.
00:13:07
shermanappel
All right, those are all the primary lesion terms that I wanted to cover. Some secondary lesion terms that I wanted to cover that you can use to describe things are ah crust and scale. They sound similar, like you might use those words interchangeably when you're making an assessment, ah but there is an important difference. A crust is dried drainage from that primary lesion, whereas scale is actually the patient's skin that is sloughed off. um So that's the key difference there.
Crust, Scale, and Secondary Lesions
00:13:37
shermanappel
Crust, dried drainage, scale the patient's skin. I like to think of it as like a serpent sheds its skin. ah That's scale, serpents have scales. Their skin is literally coming off.
00:13:50
shermanappel
um And then the last secondary one, that and this is not an exhaustive list, by the way. If you want to ah really, really brush up on your terminology for describing skin lesions, i there's plenty more of where this came from, and I would encourage you to to look into that if it's something that you're interested in. um But the last is lycanification, and that is thickening of the skin. And it just would be kind of exaggerated. It might look angry or inflamed.
00:14:18
shermanappel
Think like chronic eczema, you know, something that's like really tough and hardened. um You know, very thick skin. So that would be like canification. All right, so now we've gone through all of these words that we use to describe things. um I wanted to cover what we do when we're looking at lesions. So you're going to want to make sure that as you assess the the lesions, you go ahead and give really good adequate descriptions of the rash in general. So things that you're looking for in documentation of rashes and lesions, you want to look at the location. So you're going to describe a location, the distribution. If it's a primary or secondary lesion or distribution of lesions, ah what's the shape? Are there margins? Are the are the margins clear and well-defined?
00:15:08
shermanappel
um Are they blurred? Does it just kind of blend back into normal skin gradually or is there a sharp contrast between the rash and not rash area? ah Pigmentation or color? Is it very erythematous? Does the skin look yellow? Is it more pale than the rest of the skin? You're going to want to assess texture and then you're going to want to make sure to measure and estimate both of the area involved as well as the individual lesions if necessary. um Don't freak out. If you have a patient like me where there's just freckles everywhere, you do not have to provide an adequate description of every single freckle on my body. However, you do want to be vigilant and make sure that you don't miss any moles or nevi among those freckles that could possibly be malignant. I actually do have a nevus on my chest that I had removed when I was around 15 years old because it was prone to becoming malignant. It wasn't malignant yet, but the dermatologist was concerned enough that they felt it would be wise to remove it.
00:16:04
shermanappel
So, making sure that you're vigilant is very important, especially for your patients that have high risk factors. um four um Let's see, a normal assessment finding for a patient's skin. Let's say that they have nothing wrong with them. I wanted to cover what a normal finding documentation might look like. This is what I parsed out from ah both the textbook and my school notes. So we have a normal finding on skin assessment would be skin tone is appropriate for ethnicity, is warm, dry with good turgor, no apparent malignant knee via lesions, no rash present, even hair distribution, nails appear appropriately colored with no deformity.
00:16:44
shermanappel
Um, if you hit all of those things on a normal assessment, that should be fine. But if there's abnormalities, you want to make sure that you are providing well-documented, uh, findings. All right. So we've covered, so far we have covered the assessment of the skin hair and nails. We've covered specific terminology related to the skin assessment. Um, next I wanted to cover specific terminology related to your nails assessment. So you're going to be looking for thinning would be a symptom of vascular issues or malnutrition in patients if they're if they have very thin the brittle nails.
Nail Conditions and Health Indicators
00:17:21
shermanappel
um You're going to be considering whether or not they have it had any issues with their nutrition. ah The next word this is a 10.
00:17:29
shermanappel
10-point word on Scrabble, cholinacea. This is spoon and nails. It can be reflective of anemia, um or it could just be a congenital finding, something that has happened since birth. Perinacea, this is where there's inflammation or infection around the nail or in the nail bed. ah So if you see that reddening there, that would be perinacea. And then pitting is related to psoriasis-type conditions. And then the last one is clubbing. I'm sure that you've heard it before, but just a reminder, this is where Uh, in fact, if you do this right now, you can see if you, if you have good respiratory function, you'll see that you have a little gap in between your fingernails. If you take the tips of your fingers and just put them right together in a person that has clubbing, that angle is gone. So there will be no gap between their fingernails and their finger. Uh, you know, you can see kind of see a diamond in between mine. If you don't see that diamond there on the patient, um, then you're gonna want to be thinking about whether or not they have long-term hypoxia. It's reflective of long-term poor oxygenation.
00:18:30
shermanappel
So those are some key terms and common findings of the nails that you're going to want to make sure to investigate and document.
Hair Loss Conditions and Empathy
00:18:36
shermanappel
um And then moving on from the nails, we can go to the hair. So we have alopecia areata. This is an immune mediated response on hair follicles and it will cause patchiness where there'll just be patches of hair that are missing from the scalp or even other places on the body. um But with that alopecia, you want to make sure to be sensitive, especially in young people, because it can often be an embarrassing condition. So making sure that you're a ah being sympathetic and empathetic in your communication with the patient about their hair loss and helping to provide, ah you know, good solutions for them based off of their situation. ah The next word, this is also another one of those 10 point Scrabble words, trichotillomania. So ah if you have trichotillomania, this is when a person is pulling out and eating their own hair.
00:19:23
shermanappel
ah It can be a symptom of malnutrition. Again, it might mean that they are deficient in some nutrient and they're trying to regain it. um At least that is the the thought and theory behind that. ah Last, not not so not necessarily the last one, but tinea capitis. So when you see tinea, and then it'll be followed by a word, you have tinea capitis, you have tinea corporis, you have tinea curis, you have ah so many so many of the tinnias, lots of tinnias. Each of those second words is referring to the area of the infection. So tinea capitis is tenia as a fungal infection of the scalp. um So the common the more more common version of this is tinea corpus, which is a ringworm infection, which I'm sure that you've either seen before or seen pictures of or heard of or are familiar with. So picture that, but on your scalp, and that is tinea capitis. And you need to be specific when you're describing
00:20:20
shermanappel
ah the type of fungal infection because it does change depending on the area. For example, tinea crearis is going to be your your jock itch and so it's going to look and feel a little bit different than it would if it was a tinea corpus or ringworm on the arm or outer legs. All right, and then I also just throw in a note here when you're assessing hair that you need to Make sure that you're paying attention to hair thinning and loss or extreme hair growth because this can be reflective of a hormone disruption. So I think that that's really one of the key things to remember when you're assessing the skin hair and nails. It's often a symptom of some sort of underlying pathology when there's abnormalities.
00:21:01
shermanappel
So the questions you need to be asking yourself are going to be systemic questions, even though the finding might be isolated to the hair, skin, or nails.
Systemic Causes and Podcast Wrap-Up
00:21:10
shermanappel
ah So making sure that you take these findings and include in your deferential diagnoses, not just normally considered skin, hair, and nails pathologies, but also considering systemic ones such as hyper or hypothyroidism in relation to hair thinning or loss.
00:21:29
shermanappel
Let's see, I think that is just about everything that I wanted to talk about today. I hope that you found this podcast interesting. um You can reach me at Jackson.Jorgensen at gmail dot.com if you have any feedback. I should probably spell my name for you guys. It is J-A-X-O-N dot J-O-R-G-E-N-S-E-N at gmail dot.com. If you have any feedback for me on the show, I would love to hear it. This is my first time doing podcasts and it's really just an experiment and I'm hoping that it'll help me and you ah both come to a deeper understanding of health assessment. um I just wanted to give a little disclosure that I do not represent Baylor University in any way, nor do I represent my current employer. Anything that I say on this podcast is based off of information that I have found in my textbooks and during my course coursework and notes that I have taken.
00:22:17
shermanappel
um If you are hearing different things from your professors, make sure that you tell them what they want to hear. ah Because the the ultimate goal of this podcast is not just to get a grade, but also to learn. um But at the same time, you need to pass your classes. So ah do what your professors want. If they have a different way of doing the assessment, if they have a different way of stating things, or even if they ah directly contradict me, that's okay. Listen to them, not me. That is all for me today, and this is Jackson Jorgensen signing off.