Textbook Foundation: This lecture integrates the assessment of hair, nails, pressure injuries, wounds, burns, and documentation as presented throughout the Skin, Hair, and Nails chapter.
Good morning, class.
Today we complete our study of the integumentary system.
Many nursing students think this chapter is one of the easiest.
In reality...
It is one of the most important.
Why?
Because almost every hospitalized patient develops skin problems if nurses fail to assess and intervene appropriately.
Pressure injuries...
Burns...
Poor wound healing...
Diabetic foot ulcers...
Cellulitis...
Skin tears...
These are not simply "skin problems."
They affect:
Infection risk
Pain
Mobility
Length of hospital stay
Mortality
Quality of life
One of the nurse's greatest responsibilities is protecting the patient's skin.
By the end of today's lecture, you should be able to:
Perform a complete hair assessment.
Perform a complete nail assessment.
Differentiate normal from abnormal findings.
Assess wounds professionally.
Stage pressure injuries correctly.
Assess burns.
Document findings accurately.
Perform a complete skin, hair, and nail assessment.
Hair is much more than appearance.
It provides valuable clues about:
Nutrition
Endocrine disorders
Autoimmune diseases
Circulation
Infection
Medication side effects
Normal Hair
Healthy hair should be:
Evenly distributed
Appropriate for age and sex
Clean
Smooth
Shiny
Free of infestation
Without excessive breakage
Inspection
Observe:
Color
Distribution
Texture
Thickness
Scalp condition
Hair loss
Lesions
Infestation
Scarring
Hair Distribution
Question.
Why should nurses assess hair distribution?
Because hormonal disorders often change it.
Example:
Hypothyroidism: Hair becomes dry, Thin, Coarse.
Hyperthyroidism: Hair becomes: Fine, Soft, Fragile
Chemotherapy: Hair loss (alopecia)
Malnutrition: Thin hair, Brittle hair, Slow growth
Sudden hair loss should never be dismissed.
Ask yourself:
Is it:
Stress?
Medication?
Autoimmune disease?
Thyroid disorder?
Nutritional deficiency?
Chemotherapy?
Hair often reflects systemic disease.
Scalp Assessment
Inspect for:
Dandruff
Scaling
Redness
Lesions
Lumps
Parasites
Tenderness
Scars
Head Lice
Common findings:
Itching
Visible lice
Nits attached firmly to hair shafts
Remember:
Nits are difficult to remove because they adhere tightly to the hair.
Nails are one of the most overlooked parts of the physical assessment.
Experienced nurses never skip them.
Normal Nails
Healthy nails are:
Smooth
Firm
Slightly curved
Transparent
Pink over the nail bed
Capillary refill less than two seconds
Assess:
Color
Shape
Thickness
Curvature
Texture
Capillary refill
Clubbing
Splitting
Infection
Nail Color
Pink: Normal perfusion.
Blue: Cyanosis, Poor oxygenation, Poor circulation
Yellow: Fungal infection, Smoking, Chronic lung disease, Certain systemic conditions
White: Anemia. Liver disease, Trauma, Nutritional deficiency
Interpret in the context of the whole patient.
Clubbing
One of the most tested nursing concepts.
What is Clubbing?
Enlargement of the fingertips.
The nail angle increases.
The fingertips become bulbous.
Why Does Clubbing Occur?
Chronic low oxygen levels stimulate tissue changes around the nail beds.
Possible causes include:
Lung cancer
Cystic fibrosis
Chronic lung disease
Congenital heart disease
Certain gastrointestinal and liver diseases
Clubbing is a clue that warrants further assessment—it is not specific to one disease.
Place the nails of both index fingers together.
Normally...
A small diamond-shaped window appears between the nails.
If no window exists...
Clubbing may be present.
Patient has:
COPD
Clubbing
Barrel chest
Long smoking history
Question.
Are these isolated findings?
No.
They fit together.
Assessment is pattern recognition.
When documenting lesions...
Never write:
"Patient has a rash."
Describe exactly what you see.
Primary Lesions
These develop on previously normal skin.
Macule: Flat discoloration
Example: Freckle
Papule: Small raised lesion
Example: Wart
Vesicle: Small fluid-filled lesion
Example: Chickenpox blister
Bulla: Large blister
Pustule: Contains pus
Example: Acne
Nodule: Solid lesion extending deeper into the skin
Secondary Lesions
Develop from primary lesions or injury.
Crust: Scab
Scale: Flaking skin
Example: Psoriasis
Ulcer: Loss of skin extending into deeper tissues
Fissure: Crack in the skin
Scar: Fibrous tissue replacing injured skin
Correct:
"1-cm round erythematous papule on the left forearm. Well-defined borders. No drainage. Mild tenderness."
Incorrect:
"Looks infected."
Describe.
Don't diagnose.
This is one of nursing's highest priorities.
Pressure injuries are largely preventable.
Why Do They Occur?
Pressure compresses blood vessels.
Blood flow decreases.
Cells receive less oxygen.
Cells die.
Skin breaks down.
High-Risk Patients
Older adults
Immobile patients
ICU patients
Spinal cord injuries
Malnutrition
Diabetes
Poor circulation
Incontinence
Common Locations
Sacrum
Heels
Elbows
Hips
Ankles
Shoulders
Back of the head
Pressure Injury Stages
Stage 1
Intact skin.
Persistent redness or discoloration that does not blanch appropriately.
The skin is still intact.
Stage 2
Partial-thickness skin loss.
May appear as: a shallow open ulcer or a blister
Stage 3
Full-thickness skin loss.
Fat tissue may be visible.
Muscle, tendon, and bone are not exposed.
Stage 4
Full-thickness tissue loss.
Exposed:
Muscle
Tendon
Bone
These wounds require extensive management.
Unstageable
The wound bed is covered by slough or eschar, preventing visualization of the true depth.
You cannot determine the stage until the base can be adequately assessed.
Deep Tissue Pressure Injury
Persistent deep red, maroon, or purple discoloration, or a blood-filled blister, suggesting damage beneath intact or partially intact skin.
Prevention
Turn patients regularly according to facility policy and patient needs.
Keep skin clean and dry.
Optimize nutrition and hydration.
Use pressure-relieving surfaces when indicated.
Assess the skin frequently.
Remember:
Preventing a pressure injury is easier than treating one.
Every wound should be assessed systematically.
Assess
Location
Length
Width
Depth
Drainage
Odor
Color
Edges
Pain
Signs of infection
Surrounding skin
Drainage Types
Serous
Clear
Thin
Normal during early healing.
Sanguineous
Bright red blood.
Serosanguineous
Pink
Thin
Mixture of serum and blood.
Purulent
Thick
Yellow
Green
Brown
Often associated with infection, though laboratory evaluation is needed to confirm infection.
Signs of Infection
Increasing redness
Warmth
Swelling
Purulent drainage
Increasing pain
Fever
Delayed healing
Burn assessment is another essential nursing skill.
First-Degree Burn (Superficial)
Only the epidermis.
Findings:
Red
Painful
Dry
No blisters
Example:
Mild sunburn.
Second-Degree Burn (Partial Thickness)
Epidermis plus part of the dermis.
Findings:
Blisters
Very painful
Moist appearance
Third-Degree Burn (Full Thickness)
Destroys the epidermis and dermis.
May extend into deeper tissues.
Appearance:
White
Brown
Black
Leathery
Surprisingly...
May have little or no pain in the center because nerve endings have been destroyed.
Clinical Correlation
Patient has severe burns.
Question.
What are your biggest concerns?
Not just skin damage.
Think bigger.
Fluid loss
Hypothermia
Infection
Airway injury
Pain
Shock
Burns affect the entire body.
Comprehensive Skin Assessment
Let's perform one together.
General Survey
Observe:
Color
Mobility
Distress
Nutrition
Hygiene
Inspect
Entire skin surface as appropriate.
Hair
Scalp
Nails
Lesions
Pressure areas
Palpate
Temperature
Moisture
Texture
Mobility
Turgor
Edema
Tenderness
Nails
Capillary refill
Color
Shape
Clubbing
Hair
Distribution
Texture
Scalp
Parasites
Patient:
Diabetes
Peripheral neuropathy
Foot ulcer
Question.
Should your assessment stop at the ulcer?
No.
Assess:
Pulses
Capillary refill
Sensation
Temperature
Drainage
Footwear
Blood glucose history
Previous ulcers
Amputation history
The ulcer is only one piece of the puzzle.
Skin warm, dry, and intact except for a 2-cm partial-thickness ulcer over the right heel with a pink wound bed and scant serous drainage. Surrounding skin intact without erythema. Hair evenly distributed and scalp without lesions. Nails smooth and pink with capillary refill less than 2 seconds. No clubbing or cyanosis observed. Mild 1+ pitting edema present in both ankles.
You are assessing a 78-year-old patient who has been in bed for five days.
You observe:
Redness over the sacrum that does not blanch.
Warm skin over the affected area.
Poor nutrition.
Limited mobility.
Ask yourself:
What stage of pressure injury does this most likely represent?
What factors placed this patient at risk?
What interventions should begin immediately?
Discussion
This is consistent with a Stage 1 pressure injury because the skin remains intact but shows persistent non-blanchable redness or discoloration.
Immediate priorities include:
Relieve pressure from the area.
Reposition the patient regularly.
Assess nutrition and hydration.
Keep the skin clean and dry.
Continue frequent skin assessments.
Document findings promptly and follow facility protocols.
The nurse performs the Schamroth window test to assess for:
A. Cyanosis
B. Clubbing
C. Edema
D. Capillary refill
Answer: B
Rationale: The absence of the normal diamond-shaped window between opposing fingernails suggests clubbing.
A pressure injury has full-thickness tissue loss with exposed bone. How should the nurse classify this wound?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: C
Rationale: Stage 4 pressure injuries involve exposed muscle, tendon, or bone.
Which type of wound drainage is most suggestive of possible infection?
A. Serous
B. Serosanguineous
C. Purulent
D. Sanguineous
Answer: C
Rationale: Purulent drainage is thick and often yellow, green, or brown, and is commonly associated with infection.
A patient with long-standing chronic lung disease has enlarged fingertips and increased nail curvature. This finding is called:
A. Koilonychia
B. Clubbing
C. Onychomycosis
D. Beau's lines
Answer: B
By the end of this chapter, you have learned to assess:
Skin anatomy and physiology
Skin color and its clinical significance
Temperature
Moisture
Texture
Mobility
Turgor
Edema
Capillary refill
Hair
Nails
Primary and secondary skin lesions
Pressure injuries
Wounds
Burns
Professional documentation
You can now perform a systematic skin, hair, and nail assessment and understand how findings relate to overall patient health.
Professor's Closing Thoughts
The skin is often the first organ to reveal that the body is under stress.
A careful nurse doesn't simply see dry skin or a wound.
A careful nurse asks:
Why is this happening?
What body systems could be involved?
What complications might develop?
What can I do now to prevent the patient from getting worse?
That mindset is what transforms assessment into clinical judgment.