Assessment of Skin, Hair and Nails

By: Faridokht Yazdani Faculty of Nursing-IAUN

Skin structure. Three-dimensional view of the skin, subcutaneous tissue, glands, and hairs.

Visible changes

Palpation of Turgor

Nursing Process Care: in Skin Lesions

1. Assessment: descriptions; pt. history, causative factors

2. Evaluation of skin identify problem

3. Nursing Diagnosis

4. Interventions for skin care to promote healing and prevent further injury

- Pain management & comfort

-Infection control

1. Nursing evaluation & reassessment

Abnormal Skin Findings Primary and secondary lesions

Vascular lesions

Purpuric lesions

Infections

Malignant lesions

ABCDE Criteria

ABCDE Criteria for Melanoma Assessment

Skin Lesions Tinea

Measles

Varicella

Herpes

Psoriasis

Dermatitis

Eczema

Impetigo

Tinea corporis.

Measles (rubeola).

German measles (rubella).

Chickenpox (varicella).

Herpes simplex.

Herpes zoster (shingles).

Psoriasis.

Contact dermatitis.

Eczema (atopic dermatitis).

Impetigo.

Malignant Lesions Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Basal cell carcinoma.

Squamous cell carcinoma.

Malignant melanoma.

Abnormal Hair Findings Seborrhea

Tinea capitis

Infection

Folliculitis

Furuncles

Hirsutism

Seborrheic dermatitis (cradle cap).

Tinea capitis (scalp ringworm).

Folliculitis.

Furuncle/abscess.

Hirsutism.

Nails Assessment

Abnormal condition of nail

Ano nychia:

Platu nychia:

Koilo nychia:

Racket nail:

Onycholysis

Melano nychia:

Paro nychia:

Leuconychia

Nailfold erythema

CRF, cirrhosis

Nail clubbing