NR 306 Week 2 Skin Hair and Nails Write-Up Example

Skin, Hair and Nails Write-Up: A 38-Year-Old City Bus Operator With Deeply Pigmented Skin, Color Judged Against His Own Baseline

Student Name

College of Nursing, Chamberlain University

NR 306: Health Assessment

Instructor Name

Month Day, Year

Skin, Hair and Nails Write-Up: A 38-Year-Old City Bus Operator With Deeply Pigmented Skin, Color Judged Against His Own Baseline

Setting and Method

The volunteer, Mr. D., is a 38-year-old city bus operator who works split shifts and spends most of the day seated. He has no known skin conditions and takes no regular medicines. He was examined at 1300 in a clinic room with a window and overhead LED light, supplemented by a penlight held at an angle for surface texture. Equipment: clear plastic millimeter ruler, glass slide for blanching, gloves, and a watch with a second hand. He gave verbal consent at 1255. Terms and the order of the examination follow the course text (Jarvis & Eckhardt, 2024).

Color in deeply pigmented skin cannot be judged against a general description of pink, so each color entry below is stated against Mr. D.'s own usual tone, which he confirmed by comparing with skin on his inner upper arm, and checked at the sites where pigment is thinnest: the conjunctivae, oral mucosa, palms, soles and nail beds. A literature review of pressure injury in people with darker skin tones found that redness is often hard to see and that early skin damage in this group is detected later, which is why warmth, texture and firmness are recorded alongside color at every site where color alone would be unreliable (Oozageer Gunowa et al., 2018).

Skin: Color, Moisture, Temperature, Texture, Turgor

General color: deep brown over the face, trunk and limbs, even, matching his inner upper arm, which he describes as his usual color.

Sites of thinnest pigment: conjunctivae pink, both eyes; oral mucosa pink with scattered darker brown patches on the gums, which he says have always been there; palms and soles light tan-pink, even; nail beds pink under the brown pigment of the nail folds.

Pallor, cyanosis, jaundice: no ashen gray tone on the face or trunk; no blue tinge at the lips or nail beds; sclerae white, with no yellow tone at the hard palate.

Moisture: skin dry to the touch on the shins and outer forearms, with fine gray-white scale visible on the shins under angled light; face, axillae and palms slightly moist.

Temperature, dorsum of the examiner's hand: warm and symmetric at forehead, chest, both forearms, both shins and both feet.

Texture: smooth on the trunk and face; slightly rough over both shins.

Turgor: skin over the sternum lifted between thumb and finger and released; returned flat in under 2 seconds. Same result over the right clavicle.

Edema: none; thumb pressed for 5 seconds over each tibia and each medial malleolus left no pit.

Pressure points (sacrum, both ischial areas, both heels), as he sits most of the day: skin intact at all sites; no areas of darker discoloration compared with the surrounding skin; no difference in warmth or firmness between each site and the skin 5 centimeters away.

Lesions

Upper cheeks and below the eyes, both sides: 11 on the right and 9 on the left, dark brown to black, dome-shaped, smooth-surfaced, 1 to 3 millimeters, round, well-defined borders, raised, scattered without grouping; he says they began appearing in his twenties and his mother has similar spots.

Back of the neck at the hairline: 4 firm, skin-colored to slightly darker, raised, round bumps, 2 to 4 millimeters, each with a hair emerging from the center; mildly itchy by his report; he shaves this area with clippers every week.

Left shin, anterior, 12 centimeters below the knee: a single flat, oval, darker brown patch, 14 by 9 millimeters, even color, well-defined border, not raised; he remembers a scrape from a fall on ice two winters ago at this site.

Trunk, back and limbs otherwise: no other lesions seen with direct and angled light.

Hair

Scalp: hair black, tightly coiled, cut very short; even distribution; scalp without flakes, scars or bald patches when parted in five lines.

Face: beard kept short; even.

Body: hair present on the forearms, chest and lower legs in an even, adult male pattern; present over both shins and on the dorsum of both great toes.

Nails

Shape and surface: all 20 nails convex and smooth, without pits or ridges.

Angle at the nail base, viewed from the side: about 160 degrees on all fingers; when the dorsal surfaces of the two index fingers were placed back to back, a small diamond-shaped window was visible between the nail bases.

Nail bed color: pink beneath the nail plate on all fingers.

Pigment bands: on the right thumb and the left index finger, a single straight, even, light brown band running the full length of the nail, 2 millimeters wide on the thumb and 1 millimeter on the index finger, with no pigment spreading into the surrounding skin of the nail fold; he says he has had them "since I was a teenager."

Capillary refill, timed: each thumbnail pressed for 5 seconds at room temperature; color returned in 1.5 seconds on the right and 1.5 seconds on the left, counted on the watch.

Toenails: smooth, pink beds; nails trimmed straight across; no thickening.

Summary

Skin color was even and matched Mr. D.'s own baseline, with pink conjunctivae, oral mucosa, palms and nail beds. Dry, scaling skin was recorded over both shins. Twenty small, dark, raised facial lesions, four follicle-centered bumps at the neck hairline, and one flat pigmented patch on the left shin were measured and described. All nails had a normal base angle and window; two nails had narrow, even, longitudinal brown bands present for many years by his report. No lesion was identified by name. The narrow nail bands were shown to the instructor, who agreed that they should be recorded as observed and included in the summary for Mr. D.'s primary care provider.

Reflection

Nothing in my nursing education prepared me well to describe skin like Mr. D.'s. The textbook images of redness, pallor and cyanosis I trained on were almost all on light skin, and I realized during this examination that I have been using pink as a shorthand for normal for years. Checking the conjunctivae, mouth, palms and nail beds, and pairing color with warmth and firmness at pressure points, gave me findings I could defend. Spicknall et al. (2005) describe the nail base angle and the window between opposed nails as simple bedside checks for clubbing, and I had never done the window test before this week. I will use both at work, where I document skin on every patient and rarely write more than intact.

References

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.

Oozageer Gunowa, N., Hutchinson, M., Brooke, J., & Jackson, D. (2018). Pressure injuries in people with darker skin tones: A literature review. Journal of Clinical Nursing, 27(17-18), 3266-3275. https://doi.org/10.1111/jocn.14062

Spicknall, K. E., Zirwas, M. J., & English, J. C. (2005). Clubbing: An update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. Journal of the American Academy of Dermatology, 52(6), 1020-1028. https://doi.org/10.1016/j.jaad.2005.01.006