Assessing Skin, Hair and Nails

The integument is the only organ you can examine in full without a single piece of technology, and it is the organ most likely to tell you something before the monitor does. Skin reports perfusion, oxygenation, hydration, hepatic function, nutrition, immune status, medication reactions and — bluntly — the quality of the nursing care a patient has received. A pressure injury is one of the few adverse events that is almost always preventable and almost always attributable, which is why regulators count them. This chapter teaches you to look with intent rather than glance: how to set up the room and the light, how to move through inspection and palpation in a fixed order so you never skip the heel or the sacrum or the skin under the oxygen tubing, how to name a lesion by its primary morphology and size, how to recognize pallor, cyanosis, jaundice and erythema in every skin tone rather than only in pale skin, how to stage a pressure injury without reverse–staging it, how to chart what you saw in words a wound nurse can act on, and when to stop charting and escalate by SBAR right now.

Section 1The Skin as an Organ You Can Actually See

Three layers, and what each one tells you

The epidermis is avascular, thin as tissue paper over the eyelid and thick as a callus over the sole, and it turns over roughly every 28 days. Because it has no blood supply of its own, it is nourished by diffusion from the dermis below — which is exactly why a patient with poor perfusion gets shiny, fragile, slow–healing skin. The basal layer holds melanocytes. Every person has approximately the same number of melanocytes; what differs across skin tones is how much melanin those cells produce and how it is packaged. This single fact matters enormously at the bedside: it means a patient with deeply pigmented skin has the same underlying physiology of pallor, cyanosis and erythema as a patient with pale skin, but the visual signal is filtered through pigment. You do not change the assessment. You change where you look.

The dermis is the working layer: collagen and elastin for tensile strength and recoil, capillary loops for the color you see through the epidermis, sensory nerve endings for touch, pressure, temperature and pain, and the sebaceous and sweat glands. When you assess turgor you are testing dermal elastin and interstitial fluid. When you see erythema you are seeing dilated dermal capillaries. When a Stage 2 pressure injury shows a pink, moist, shiny wound bed, you are looking directly at exposed dermis — and because the dermis holds the nerve endings, that wound hurts. A wound that has destroyed the dermis entirely, on the other hand, may be strangely painless, which is a warning sign rather than a reassurance.

The subcutaneous layer (hypodermis) is adipose and connective tissue. It insulates, cushions bony prominences and stores energy. This is why the cachectic patient, the frail older adult and the critically ill patient who has lost 12 kg in three weeks are at extreme pressure–injury risk: the padding over the sacrum, ischial tuberosities, greater trochanters, heels and occiput is simply gone. When you can see visible adipose in a wound bed, you are looking at a full–thickness injury — at minimum a Stage 3.

The appendages: hair, nails and glands

Hair follicles, nails, eccrine sweat glands, apocrine glands and sebaceous glands are all epidermal derivatives, which is why systemic illness marks all of them at once. Eccrine glands are distributed nearly everywhere and are your thermoregulatory workhorse; diaphoresis in a patient who is not hot is a sympathetic surge and deserves a set of vital signs, not a towel. Apocrine glands sit in the axillae and groin, become active at puberty and produce body odor when bacteria act on their secretions. Sebaceous glands produce sebum, which keeps the stratum corneum pliable; they decline with age, which is one reason older adults develop xerosis (dry, scaling, itchy skin) and why moisturizing is a nursing intervention rather than a courtesy.

Nails are keratinized plates growing from the nail matrix under the proximal fold. Fingernails grow about 0.1 mm per day — roughly 3 mm per month, so a full fingernail replaces itself in about six months. Toenails grow at about a third of that rate and take 12 to 18 months. That growth rate is clinically useful: if you see a transverse groove (a Beau line) 6 mm from the cuticle, the systemic insult that arrested nail growth happened roughly two months ago. Hair likewise grows in cycles, and a diffuse shed two to three months after a major stressor — childbirth, sepsis, surgery, severe illness — is telogen effluvium, not disease.

Functions, and the assessment question each one implies

Teaching the functions of skin as a memorized list wastes them. Each function is really an assessment question. Barrier: is the skin intact, and where is it not? Thermoregulation: is this patient hot, cold, diaphoretic, mottled? Sensation: can this patient feel the pressure of their own heel on the mattress, or has neuropathy, spinal cord injury, sedation or an epidural taken that protective feedback away? Vitamin D synthesis, immune surveillance via Langerhans cells, fluid and electrolyte conservation, excretion, and identity — the face and hands a patient recognizes as their own. That last one is not sentimental. Disfiguring skin disease and visible wounds carry real psychological weight, and a patient who will not look at their own stoma or their own burn is telling you something you must document and address.

Baseline variation across the lifespan

Nothing in skin assessment makes sense until you know what is normal for the age in front of you. A newborn is covered in vernix caseosa and fine lanugo, has pinpoint white milia across the nose and chin, and commonly develops erythema toxicum neonatorum — blotchy erythematous macules with tiny central papules appearing at 24 to 72 hours and resolving on its own. Acrocyanosis (blue hands and feet with a pink trunk and pink mucous membranes) is expected in the first 24 to 48 hours of life. Central cyanosis — blue lips, tongue and oral mucosa — is never normal at any age. Congenital dermal melanocytosis, the blue–gray patches over the sacrum and buttocks seen most often in infants with darker skin tones, is a benign finding that must be documented on admission with location and size so it is never mistaken for bruising.

Older adults lose dermal thickness, elastin, subcutaneous fat, sebum and capillary density. Expect thin, dry, wrinkled, cool skin; solar lentigines (liver spots); seborrheic keratoses (the greasy, stuck–on brown plaques); cherry angiomas; and senile purpura — flat, dark purple patches on the forearms and dorsal hands from fragile vessels and thin dermis, which is not evidence of abuse by itself. Turgor is unreliable over the hand in an older adult; test over the sternum or below the clavicle instead. In pregnancy expect melasma, linea nigra, striae gravidarum, spider angiomas and palmar erythema, all driven by estrogen and increased cutaneous blood flow.

Section 2Technique: How the Examination Is Actually Performed

The order of techniques, and the one exception you must memorize

The standard sequence of physical examination is inspection, palpation, percussion, auscultation — least invasive to most, so that each technique does not corrupt the one after it. For the integument only the first two apply: you inspect, then you palpate. There is nothing to percuss and nothing to auscultate on skin, with the narrow exception of listening over a vascular lesion or graft for a bruit. Learn the four–step order anyway, because it governs every other regional examination in this book.

The exception is the abdomen, and it is the single most tested sequence variation in nursing school: inspect, auscultate, percuss, palpate. Auscultation moves to second position because percussing and palpating the abdomen mechanically stimulates the bowel and alters the frequency and character of bowel sounds. If you palpate first, whatever you hear afterward is an artifact of your own hands. Every other region — skin, thorax, heart, extremities — keeps inspection, palpation, percussion, auscultation.

Two more sequencing rules matter for skin. First, inspect and palpate region by region as you undrape, rather than exposing the whole patient at once; this preserves dignity and warmth and reduces the chance you skip a region. Second, always compare side to side. Symmetry is your control group. A warm, red, swollen left calf means far more when you have just palpated a cool, normal right calf thirty seconds earlier.

Setting up: light, warmth, gloves, ruler

Poor lighting is the most common reason a skin finding is missed. Use natural daylight if you can, or a strong daylight–balanced overhead light plus a penlight; fluorescent light adds a green cast that masks jaundice, and the amber glow of a night light will hide early erythema entirely. Use tangential lighting — shine the penlight across the surface at a low angle — to raise the shadow of a lesion that is flat under direct light and to reveal the subtle contour of a healing wound. Warm the room; a cold patient will be pale, mottled and vasoconstricted, and you will misread perfusion. Perform hand hygiene, wear gloves for any contact with non–intact skin, mucous membrane or drainage, and change gloves and repeat hand hygiene between a wound and clean skin, and between one wound and the next.

Carry a flexible centimeter ruler, not an inch ruler and not your own estimate. “Dime–sized” and “golf–ball–sized” are not measurements and cannot be trended. Carry a penlight, a magnifier if available, and know that a transparent glass slide or clear plastic pressed on a red lesion (diascopy) will tell you whether it blanches — a two–second maneuver that separates a benign erythema from a hemorrhagic rash.

A repeatable head–to–toe route

Use the same route every time so that omission becomes impossible. Scalp and behind the ears, then face, then neck and the skin folds under the chin, then anterior trunk including under the breasts and in the axillae, then arms and hands with the palms and interdigital webs, then abdomen and the panniculus folds, then perineum and the gluteal cleft, then legs, then feet including between every toe and the plantar surfaces, then log–roll and inspect the entire posterior surface: occiput, scapulae, spine, sacrum, ischial tuberosities and heels. Then inspect under and around every device — oxygen tubing over the ears and nares, the nasogastric tube against the nostril, pulse oximeter probes, the collar of a cervical brace, compression sleeves, casts, ID bands, the tubing coiled under the patient’s thigh. Device–related pressure injuries are common and they conform to the shape of the device.

On palpation you are gathering five things: temperature, moisture, texture, turgor and mobility, plus tenderness and any masses. Use the dorsum of your hand for temperature because it is more thermally sensitive than the palm, and compare bilaterally. Test turgor by gently pinching a fold of skin — over the sternum or beneath the clavicle in adults and especially in older adults, over the abdomen or inner thigh in infants. Expected: the fold returns immediately, in under 2 seconds. Tenting that persists 3 seconds or more suggests volume depletion, though it is unreliable in isolation in older adults, so pair it with mucous membranes, urine output, orthostatic vital signs and daily weight. Assess capillary refill by pressing the nail bed or a fingertip pulp for 5 seconds and releasing; expected refill is under 2 seconds in adults and children.

Edema, and the numbers that frame every skin finding

Grade pitting edema by pressing your thumb firmly over a bony prominence — the tibia, the medial malleolus, the dorsum of the foot, or the sacrum in a bedbound patient — for 5 seconds and then observing the indentation. The conventional scale is 1+ = about 2 mm, barely detectable, rebounds immediately; 2+ = about 4 mm, rebounds in a few seconds; 3+ = about 6 mm, deep pit, the limb looks swollen, rebound may take 10 to 30 seconds; 4+ = about 8 mm, very deep pit, gross swelling, indentation lasts more than 30 seconds. Record the grade, the depth, the location and how far up the limb it extends: “3+ pitting edema bilateral lower extremities to mid–calf” is usable data.

Skin findings are interpreted against vital signs, so know the real numbers. In a healthy adult: oral temperature 36.5 to 37.5 °C (97.7 to 99.5 °F) with an average near 37 °C (98.6 °F); pulse 60 to 100 beats per minute; respirations 12 to 20 per minute; blood pressure less than 120/80 mm Hg as normal; oxygen saturation 95 to 100 percent on room air. A hot, red, tender leg with a temperature of 38.6 °C, a heart rate of 118 and a systolic of 88 is not a dermatology consult — it is sepsis until proven otherwise.

Two lifespan cautions. Infants and young children lose heat fast because of a high body–surface–area–to–mass ratio and thin subcutaneous fat, so uncover them briefly and re–cover them. Older adults run a lower baseline temperature and blunt the febrile response, so a reading of 37.8 °C (100 °F), or a rise of 1.1 °C (2 °F) above that person’s own baseline, can represent significant infection — a cellulitis in an 84–year–old may present as new confusion and a temperature of 37.6 °C rather than a spiking fever.

Section 3Color, Lesions and Vascular Findings — Normal Beside Abnormal

Reading color in every skin tone

The traditional description of cyanosis as “bluish skin” and pallor as “white skin” was written for one narrow band of complexions, and students who learn it that way miss hypoxia in patients with deeply pigmented skin. Fix this by changing your viewing windows, not your standards. For cyanosis, examine the oral mucosa, tongue, lips, conjunctivae, nail beds, palms and soles; in darker skin tones cyanosis appears ashen, gray or dusky rather than blue, and the tongue and buccal mucosa are the most reliable sites because they are minimally pigmented in almost everyone. Never wait for cyanosis to diagnose hypoxia; it requires roughly 5 g/dL of deoxygenated hemoglobin, which means a severely anemic patient can be dangerously hypoxic and never turn blue at all.

For pallor, examine the conjunctivae, oral mucosa, nail beds and palmar creases. In brown skin, pallor may look yellow–brown; in black skin, ashen or gray; the underlying skin loses its normal red undertone. For jaundice, examine the sclerae (near the limbus, avoiding the peripheral fat pad, which can look yellow normally in darker–skinned patients), the hard palate under bright light, the sublingual area, and the palms and soles. For erythema, do not rely on redness at all in deeply pigmented skin: it presents as a deeper violet, purple, maroon or eggplant hue and is often invisible under artificial light. Instead palpate — compare the area to the same site on the opposite side for increased warmth, induration, firmness, boggy softness, edema and tenderness, and ask the patient whether that spot itches, burns or hurts. Warmth and induration in a patient reporting pain over a bony prominence is a Stage 1 pressure injury or early cellulitis whether or not you can see red.

Naming the lesion: primary, secondary, size

A primary lesion arises on previously normal skin. A secondary lesion results from a change in a primary lesion — scratching, infection, healing or time. Naming the morphology and giving a measurement in centimeters is what turns your note into data. “Rash on chest” is useless. “Multiple erythematous, blanchable macules 2 to 4 mm, coalescing into patches up to 6 cm, distributed over anterior chest and both upper arms, sparing palms and soles, no mucosal involvement” lets a provider act from the hallway.

Configuration, distribution and blanching

Three modifiers finish the description. Configuration: annular (ring), linear, grouped or herpetiform, target/iris, serpiginous, confluent. Distribution: localized, generalized, symmetric, dermatomal, sun–exposed, intertriginous, acral (hands and feet). Distribution is diagnostic on its own — a painful vesicular eruption in a band on one side of the trunk that stops abruptly at the midline is herpes zoster, following a single dermatome; a symmetric rash on palms and soles carries an entirely different differential than the same rash on the trunk.

Blanching is the fastest and highest–yield maneuver in the entire skin examination. Press a red area with your fingertip or a clear slide for 3 seconds and release. If it whitens and refills, the redness is intravascular — blood inside dilated vessels — and the causes are inflammation, fever, flushing, drug eruption, reactive hyperemia. If it does not blanch, blood has leaked out of the vessels into the tissue, and the differential turns serious: petechiae, purpura, thrombocytopenia, vasculitis, meningococcemia, disseminated intravascular coagulation. Non–blanching erythema over a bony prominence in skin that is still intact is, by definition, a Stage 1 pressure injury — but if that non–blanchable area is deep red, maroon or purple, or is a blood–filled blister, call it a deep tissue pressure injury instead, because it is deeper and can deteriorate within hours.

The lesion you must not walk past: ABCDE

Nurses see more undressed skin than any other clinician, which makes you the most likely person to find a melanoma. Screen every pigmented lesion with ABCDE: Asymmetry (one half unlike the other), Border irregular, notched or blurred, Color varied within a single lesion — brown, black, red, white, blue, Diameter greater than 6 mm (about a pencil eraser), Evolving — changing in size, shape, color, elevation, or newly itching, bleeding or crusting. Add the ugly duckling rule: the mole that looks unlike all the patient’s other moles deserves attention even if it passes ABCDE. Evolution is the most important letter; a patient who says “that one has changed” is reporting a red flag.

Skin cancer is not a light–skin–only disease, and the reason patients with darker skin tones have worse melanoma survival is later detection. The most common melanoma subtype in Black patients is acral lentiginous melanoma, which appears on the palms, soles, and under the nails — sites that get skipped by clinicians who inspect only sun–exposed skin. So examine the soles and the interdigital spaces on every patient, and take a new dark longitudinal band in a nail, especially one that widens or spreads pigment onto the surrounding nail fold, as a finding to report rather than a cosmetic curiosity.

Section 4Hair, Scalp and Nails

Hair and scalp

Inspect and palpate hair for distribution, quantity, texture, color and the condition of the scalp beneath it — separate the hair in several places rather than looking at the surface, and always inspect behind the ears and at the nape, where lice, seborrheic scale and device pressure hide. Expect terminal hair on the scalp, axillae and pubic area after puberty and fine vellus hair elsewhere. Expect gradual thinning, graying and reduced axillary and pubic hair in older adults.

Patterns matter more than amount. Alopecia areata produces sharply defined round bald patches with smooth underlying scalp. Traction alopecia thins the frontal and temporal hairline and follows tight braids, weaves, extensions or a ponytail worn the same way for years; it is reversible early and permanent late, which makes it a genuine teaching opportunity rather than a cosmetic aside. Telogen effluvium is a diffuse shed 2 to 3 months after childbirth, surgery, severe illness or major weight loss and regrows. Tinea capitis gives scaly patches with broken–off hairs and is contagious. Hirsutism — coarse terminal hair in a male pattern on a female patient’s face, chest or abdomen — warrants reporting for endocrine evaluation.

One hair finding is a vascular emergency in slow motion: loss of hair over the lower legs, ankles and toes together with shiny, thin, cool, pale skin and thickened nails is classic peripheral arterial disease. Pair that with dependent rubor, pallor on elevation, diminished pulses and painful, punched–out ulcers on the toes or lateral malleolus, and you have a limb at risk. Contrast it with venous insufficiency: warm limb, brown hemosiderin staining, edema, and a shallow, weepy, irregular ulcer at the medial malleolus. The two are managed in opposite directions — compression helps venous disease and can destroy an arterial limb — so the distinction is not academic.

Nails: angle, surface, color, and the bed beneath

Inspect nail shape, contour, surface, thickness, color and the surrounding folds, and palpate the nail plate for firmness and adherence to the bed. The normal nail base angle (Lovibond angle) is approximately 160 degrees; the nail is firmly adherent, smooth, and the bed is pink with capillary refill under 2 seconds. In clubbing the angle flattens and then exceeds 180 degrees, the nail base becomes spongy or floating, and the fingertip bulbs. Use the Schamroth window test: have the patient place the dorsal surfaces of two matching fingernails together. Normally a small diamond–shaped window of light appears between them; in clubbing the window disappears. Clubbing develops over months and points to chronic hypoxemia or shunting — cystic fibrosis, congenital cyanotic heart disease, bronchiectasis, interstitial lung disease, lung cancer, cirrhosis, inflammatory bowel disease.

Infestations and the findings that change the room

Pediculosis capitis (head lice) shows as intense itching with tiny gray–white nits cemented to hair shafts, most densely behind the ears and at the nape; nits found within about 6 mm (a quarter inch) of the scalp indicate active infestation, while nits far out on the shaft are usually old. Scabies presents as relentless itching that is worst at night with thin, wavy burrows in the finger webs, flexor wrists, axillae, waistband area, and genitals; in infants it involves the palms, soles and scalp. Both findings change nursing practice immediately: initiate contact precautions per facility policy, bag linens, notify the provider and infection prevention, and treat the itching as real distress rather than a complaint. Neither is a marker of poor hygiene, and telling the patient so plainly is part of care.

Section 5Skin Integrity, Documentation, Red Flags and Scope

Risk, prevention and the Braden Scale

Pressure injuries develop where soft tissue is compressed between bone and a surface long enough to occlude capillary flow, and they are accelerated by shear, friction, moisture, poor nutrition and impaired sensation. Assess risk on admission, at every shift change or per facility policy, and with any change in condition, using the Braden Scale. It scores six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction and shear — for a total of 6 to 23, where a lower score means higher risk. Conventional cutoffs: 19 to 23 no risk, 15 to 18 mild, 13 to 14 moderate, 10 to 12 high, 9 or below very high. A score of 18 or less should trigger a prevention bundle, and many facilities use a higher threshold for older adults and patients with darker skin tones because visual detection of early injury is less reliable.

The prevention bundle is nursing work, not an order set: reposition a bedbound patient at least every 2 hours and a chair–bound patient every 1 hour (or teach small shifts every 15 minutes if they can); use a 30–degree lateral tilt rather than direct side–lying on the trochanter; keep the head of bed at 30 degrees or less unless contraindicated, because higher elevation drives shear at the sacrum; float the heels off the bed entirely with a pillow under the calves or a heel offloading boot; use lift sheets and never drag; keep skin clean and dry with a barrier product for incontinence; optimize protein and calorie intake and involve dietitian services; and do not massage over bony prominences or reddened areas — massage over compromised tissue increases damage.

Staging — and the errors that get students in trouble

Four rules save you. First, do not reverse–stage. A healing Stage 4 does not become a Stage 2; it is a “healing Stage 4” forever, because lost muscle and fat are replaced by scar, not by the original tissue. Second, do not stage a wound that is not a pressure injury. Staging language belongs only to pressure injuries; skin tears, surgical wounds, venous ulcers, arterial ulcers, diabetic foot ulcers and burns are described by depth and characteristics instead. Third, do not remove stable eschar on a heel. Dry, adherent, intact eschar on an ischemic heel without erythema, fluctuance, drainage or odor is a biological cover; leave it, offload the heel and report. If it becomes soft, boggy, draining or surrounded by erythema, escalate. Fourth, distinguish pressure injury from moisture–associated skin damage.

How to chart it

Documentation is a clinical intervention. It is how the next nurse detects deterioration, how the wound team plans, and how the record demonstrates that an injury was present on admission rather than acquired on your unit. Chart what you observed and measured, not what you concluded. Wounds are measured in centimeters as length × width × depth, with length head–to–toe and width side–to–side, and undermining or tunneling described by depth in centimeters and by clock position with 12 o’clock toward the patient’s head.

Red flags and the SBAR that follows

Some skin findings buy you hours. These do not.

Escalate with SBAR, which turns anxiety into a plan. Situation: “Dr. Ellis, this is Marcus Reed, RN, on 4 West. I’m calling about Mr. Alvarez in 412 — I’m concerned he has a rapidly spreading soft–tissue infection of the right leg.” Background: “He’s a 62–year–old admitted two days ago for cellulitis after a lawn–mower laceration, on IV vancomycin, with type 2 diabetes and an A1c of 9.4.” Assessment: “At 1800 the erythema was marked at the ankle. It’s now 3 cm past that mark, the skin is dusky with two tense bullae, I feel crepitus over the lateral calf, and his pain is 9 out of 10 and out of proportion to what I see. Temperature 38.9, heart rate 124, respirations 26, blood pressure 92/54 down from 132/78, SpO2 94 percent on room air.” Recommendation: “I need you to see him now. I’ve activated rapid response, held his diet, and I’m requesting surgical consult, blood cultures and fluid resuscitation orders.” Notice the recommendation is specific. “Something is wrong” is not an SBAR.

Delegation and scope

The five rights of delegation — right task, right circumstance, right person, right direction and communication, right supervision and evaluation — apply constantly in skin care, because so much skin work happens during hygiene, which is frequently delegated. The line is simple and absolute: assessment, interpretation, staging, teaching, evaluation and the care of an unstable patient stay with the RN. Unlicensed assistive personnel may observe and report what they see; they may never assess what it means. Delegating a task never delegates accountability, and the RN must give explicit direction about what to report and when.

Words worth knowing