Lecture Notes

Assessing the Nails

purposes
1. to determine changes in the internal environment of the body
2. to yield valuable information on general health status
3. to provide information needed to identify specific systemic diseases
4. to determine the status of the structure that protects the distal ends of the fingers and toes
structure and function
1. function
  1. protect the distal ends of the fingers and toes
2. structure
  1. nail matrix (root)
    1. not visible
    2. located at the proximal end of the nail plate
    3. is where the nail plate is developed
  2. nail plate
    1. has a fixed middle portion
    2. has a distal free edge
  3. lunula
    1. white, opaque semilunar area at the proximal end of the nail plate
  4. proximal nail fold
    1. overlaps the proximal end of the nail plate
  5. lateral nails folds
    1. overlap the sides of the nail plate
  6. cuticle
    1. extends from the proximal nail fold
    2. functions as a seal to protect the space between the proximal nail fold and the nail plate from external moisture
pertinent history
1. adults
  1. change in nails
  2. self-care behaviors
  3. usual state of health
preparation of the patient and environment
1. patient
  1. greet the patient and establish rapport
  2. explain the procedure to the patient in simple terms what will be done, what he/she should expect, and how he/she can cooperate during the examination
  3. assist the patient in assuming a position of sitting up straight with his/her head at eye level
  4. encourage the patient to ask questions and mention any discomfort he/she feels during the examination
2. environment
  1. private
  2. adequately lit
  3. warm
techniques of examination
1. inspect the curvature of the nail plate of the nail
  1. observe the curvature of the nail plate of the nail from all angles
  2. normal findings:
    1. nail plate is flat or slightly curved
  3. deviations from normal findings:
    1. spoon shaped nail
      1. e.g., koilonychia (spoon nail)
        
        an abnormality of the nails, that commonly occurs as a result of heredity or iron deficiency anemia, in which the nail plate thins and the lateral edges of the nail plate lift up forming a concave profile
2. inspect the folds around the nail plate of the nails
  1. observe the folds around the nail plate of the nail from all angles
  2. normal findings:
    1. the folds around the nail plate are smooth, rounded, warm, and nontender
    2. the color of the folds around the nail plate is consistent with genetic background
  3. deviations from normal findings:
    1. the folds around the nail plate are swollen, hot, tender, and reddened
      1. e.g., paronychia
        
        an abnormality of the nails, that commonly occurs as a result of a bacterial or fungal infection, in which the folds around the nail plate are swollen, hot, tender, and reddened
3. inspect the edges of the nails
  1. observe the edges of the nails from all angles
  2. normal findings:
  1. deviations from normal findings:
4. inspect the angle between the nail plate and nail base
  1. observe the angle between the nail plate and nail base from all angles
  2. normal findings:
    1. angle between the nail plate and nail base is 160 degrees
  3. deviations from normal findings:
    1. the angle between the nail plate and nail base is greater than 180 degrees
      1. e.g., clubbing
        
        an abnormality of the nails, that commonly occurs a result of conditions (e.g., cyanotic heart disease, cystic fibrosis, and acquired immune deficiency syndrome) that lead to impaired tissue perfusion for a long period of time, in which the angle between the nail plate and nail base is greater than 180 degrees, the nail plate is more convex, the distal phalanx is rounded and bulbous, and the proximal nail fold is spongy or floating
5. palpate the nails for adhesion
  1. palpate the nails for adhesion, by:
    1. grasping each of the patient's nails between the thumb and pad of the index finger of your right hand
    2. squeezing each of the patient's nails between the thumb and pad of the index finger of your right hand
    3. observing the movement of the patient's nail plate between the thumb and pad of the index finger of your right hand
  2. normal findings:
    1. nail plate is firmly adherent to the nail bed with only a slight degree of mobility
    2. nail base is firm
  3. deviations from normal findings:
    1. the nail plate is not firmly adherent to the nail bed and has an increased degree of mobility and the nail base is spongy or floating
      1. e.g., onycholysis
        
        an abnormality of the nails in which the nail plate is loosened from the nail bed, usually starting at the distal edge and progressing proximally
6. inspect the surface of the nail plate
  1. observe the surface of the nail plate from all angles
  2. normal findings:
    1. surface of the nail plate is regular, even
  3. deviations from normal findings:
    1. surface of the nail plate is irregular, uneven
      1. e.g., Beau's lines
        
        an abnormality of the nails, that commonly occurs as a result of an acute, severe illness (e.g., hepatic or renal disease), in which the nail plate has a transverse groove on it parallel to the lunula that extends down to the nail bed
      2. e.g., pitting
        
        an abnormality of the nails, that commonly occurs as a result of psoriasis, in which there are small pits in the nails
      3. e.g., longitudinal ridging
        
        an abnormaility of the nails, that commonly occurs as a result of aging, in which the nail plate has parallel, elevated nail ridges
7. inspect the color of the nail plate and the nail bed underneath the nail plate
  1. observe the color of the nail plate and the nail bed underneath the nail plate from all angles
  2. normal findings:
    1. nail plate is translucent
    2. color of the nail bed underneath the nail plate is consistent with genetic background
    3. nail bed underneath the nail plate has brownish-black pigmented areas or linear streaks along the nail edge in dark-skinned people
  3. deviations from normal findings:
    1. nail plate is opaque
    2. color of the nail bed underneath the nail plate exhibits pallor, cyanosis
    3. nail bed underneath the nail plate has brownish-black pigmented areas or linear bands or streaks along the nail edge (in light-skinned people)
      1. e.g., melanoma
    4. nail plate is mostly white with a distal band of red-brown
      1. e.g., Terry's nails
        
        an abnormality of the nails, that commonly occurs in people with chronic conditions (e.g., cirrhoses of the liver, congestive heart failure, non-insulin dependent diabetes), in which the nails are mostly whitish with a distal band of reddish brown
    5. nail plate has a transverse white line or band
      1. e.g., Mees' bands
        
        an abnormality of the nails, that commonly occurs as a result of an acute, severe illness (e.g., hepatic or renal disease), in which the nail plate has a transverse line or band on it parallel to the lunula
    6. nail bed underneath the nail plate has reddish-brown, linear streaks
      1. e.g., splinter hemorrhages
        
        an abnormality of the nails, that commonly occurs with subacute bacterial endocarditis, trichinosis, and/or minor trauma, in which there are red-brown, linear streaks in the nail bed
8. inspect the thickness of the nails
  1. observe the thickness of the nails from all angles
  2. normal findings:
    1. thickness of the nail plate is even, unridged
  3. deviations from normal findings:
    1. thickness of the nail plate is uneven, ridged
      1. e.g., fungal infection

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This page was last modified on 1/1/03