{"id":1043,"date":"2022-12-12T11:55:58","date_gmt":"2022-12-12T16:55:58","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/?post_type=chapter&#038;p=1043"},"modified":"2024-03-21T16:41:16","modified_gmt":"2024-03-21T20:41:16","slug":"nails-inspection-and-palpation","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/chapter\/nails-inspection-and-palpation\/","title":{"raw":"Nails: Inspection and Palpation","rendered":"Nails: Inspection and Palpation"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\">Inspection and palpation of nails can be accomplished with the client in a sitting upright position or lying supine. Nail polish or artificial nails must be removed to fully assess the nails. You will need to decide if a full nail assessment is warranted depending on the nature of the visit, the reason for seeking care and the client\u2019s status. If appropriate, remind the client to arrive without nail polish or artificial nails before their appointment.\u00a0<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Steps for nail inspection and palpation include:<\/span><\/p>\r\n\r\n<ol>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Inspect the nail condition<\/strong> and <strong>nail colour<\/strong> by asking the client to hold their hands out in front of them (<strong>Figure 10<\/strong>).<\/span><\/li>\r\n<\/ol>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-300x200.jpg\" alt=\"Nurse inspecting client's nail condition.\" class=\"alignnone wp-image-1253\" width=\"427\" height=\"284\" \/>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 10<\/strong>: Inspection of nails. <\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">(Licensed under a Creative Commons Attribution-Non-commercial 4.0 License. Arthur Labatt Family School of Nursing, \"Nail Colour Assessment\" (2021). Respiratory Exams. <\/span><a href=\"https:\/\/ir.lib.uwo.ca\/clinicalskills_respexam\/15\" target=\"_blank\" rel=\"noopener\">https:\/\/ir.lib.uwo.ca\/clinicalskills_respexam\/15<\/a><span style=\"color: #000000\">)<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Normally, the ends of the nails are smooth and nails are clean. A client\u2019s job may influence nail cleanliness. Nails are translucent in colour and have a slight pinkish tone. <\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Abnormal findings may include ridges, pitting, brittleness, indentations, and discolourations. If you note any abnormal nail condition or discolouration, describe the appearance and location, e.g., white markings at the base of the nail on the left index finger. <strong>Table 9<\/strong> lists some nail variations that you may observe. Yellowing or darkening of the nails is a common discolouration associated with nail fungus (see <strong>Figure 11<\/strong>)<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Landmark digits (fingers and toes) appropriately. Many institutions have a body diagram to landmark anatomy. Check with your institution for specific nomenclature, which can vary in terms of how digits are referenced. Sometimes the thumb as referred to as Digit 1, index finger as Digit 2, middle finger as Digit 3, ring finger as Digit 4, and little finger as Digit 5. If you are uncertain about how to reference a specific digit, landmark as descriptively as possible (e.g., middle finger left hand, 2nd medial toe right foot).\u00a0<\/span><\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<span style=\"color: #000000\"><strong>Table 9:<\/strong> Nail colour changes.<\/span>\r\n<div align=\"left\">\r\n<table class=\"grid\">\r\n<tbody>\r\n<tr class=\"shaded\">\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Colour Variation<\/strong><\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Description<\/strong><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">White<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Loss of pigmentation (pinkness) and whitening of the nail bed can be the result of lack of perfusion related to illnesses like diabetes and liver disease.\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Blue<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Blue hue of the nail bed can be an indication of hypoxia.\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Yellow<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Yellowing of the nails can be a sign of chronic lung disease or lymphedema: over time, the nails thicken and become yellow due to lack of drainage of lymph fluid under the nail bed. Yellowing can also be a sign of rheumatoid arthritis or fungal infection. Smoking can also discolour the nail and leave yellow nicotine stains.\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Red\/brown half-moons<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Red half-moons may be a sign of auto-immune disorder.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Blue half-moon<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">A blue-half moon is a sign of poisoning (e.g., silver).\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Black stripe<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">A black stripe that runs down the nail bed can be a sign of melanoma, but also can be benign.\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"vertical-align: top;width: 264.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Greenish black<\/span><\/p>\r\n<\/td>\r\n<td style=\"vertical-align: top;width: 584.988px\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Bacterial infection under the nail can cause a greenish black appearance (see <strong>Figure 11<\/strong>).\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-225x300.jpg\" alt=\"A person's right foot. The big toe is discoloured at the base with a line down the middle which is nail fungus.\" class=\"alignnone wp-image-1255 size-medium\" width=\"225\" height=\"300\" \/> <img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-225x300.jpg\" alt=\"A person's left foot. The big toe is yellowish in colour and has nail fungus.\" class=\"alignnone wp-image-1256 size-medium\" width=\"225\" height=\"300\" \/>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 11:<\/strong> Nail fungus.<\/span><\/p>\r\n\r\n<ol start=\"2\">\r\n \t<li><span style=\"color: #000000\"><strong>Assess for the presence of clubbing<\/strong> (see <strong>Figure 12<\/strong>\u00a0and <strong>Video 4 <\/strong>and <b>5<\/b>). Clubbing is related to conditions that lead to chronic hypoxia (e.g., chronic lung diseases, cystic fibrosis, congenital heart disease). Chronic hypoxia can cause the nail angle to flatten to 180 degrees or more, the nail bed to soften and become spongy, and the fingertips distal to the distal interphalangeal joint to become enlarged. Clubbing typically first develops in the thumb and then the forefingers. It is often assessed on the index finger, but in cases of early clubbing it may not have advanced to that digit, so it is best to assess the thumb first. To assess for the presence of clubbing, ask the client to point their thumb out so that it is parallel to the ground and view it at your eye level (this is considered the profile sign). Inspect the nail angle at the intersection of where the nail base meets the skin.\r\n<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normally, the nail angle base is about 160 degrees with normal-sized fingertips and nail beds that are firm to touch.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Clubbing is evident when the angle of the nail base is greater than 180 degrees (flattening of the nail base); fingertips are usually enlarged and bulb-like, and the nail base is spongy\/soft upon palpation.\u00a0<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong><img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-1024x768.jpeg\" alt=\"Two hands showing bulbed-like fingertips.\" width=\"450\" height=\"338\" class=\"alignnone wp-image-1531\" \/><\/strong><\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 12:<\/strong> Clubbing.<\/span><\/p>\r\n(Photo by Sidsandyy, CC BY-SA 3.0, <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=40100295\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=40100295<\/a>)\r\n\r\n&nbsp;\r\n\r\n[embed]https:\/\/youtu.be\/aZOQQOWX1wU[\/embed]\r\n\r\n<span style=\"color: #000000\"><strong>Video 4<\/strong>: Inspection for clubbing on the index finger [0:19]<\/span>\r\n\r\n&nbsp;\r\n\r\nhttps:\/\/youtu.be\/g-GgVvSvsJk\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 5:<\/strong> Inspection for clubbing on the thumb [0:18]<\/span><\/p>\r\n\r\n<ol start=\"3\">\r\n \t<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\"><strong>Palpate the nails for texture and consistency<\/strong> using a grasping motion: place the pad of your index finger on the client\u2019s nail and your thumb on the underside of the client\u2019s finger. Palpate the whole nail including the nail bed.<\/span><span style=\"color: #000000\">\r\n<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normally, nails are smooth and firm.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Describe the appearance and location of thick nails and spongy\/soft nails.\r\n<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<ol start=\"4\">\r\n \t<li><span style=\"color: #000000\"><strong>Palpate the nails for capillary refill<\/strong> on two or three fingernails of each hand, at heart level (see <strong>Video 6<\/strong>). Start by applying pressure with your own finger to the client\u2019s nail; this causes the nail to blanch (become paler in colour). Apply the pressure for 5 seconds and then release and observe the return in colour.\r\n<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\"><span style=\"font-size: 1em\">A normal finding when assessing capillary refill is colour return within 3 seconds or less.<\/span><\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Colour return taking longer than 3 seconds is considered sluggish return for capillary refill (or slow capillary refill time), and this finding suggests possible issues with [pb_glossary id=\"1829\"]oxygenated blood perfusion[\/pb_glossary] (this may be related to peripheral vascular and\/or cardiac and\/or respiratory issues). Note that capillary refill time can be slower if the client\u2019s hands are cold from being outside or from washing in cold water; ask them to warm their hands to ensure an accurate reading.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n[embed]https:\/\/youtu.be\/CXGN89Bkl-0[\/embed]\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 6:<\/strong> Capillary refill [0:45]\u00a0<\/span><\/p>\r\n\r\n<ol start=\"5\">\r\n \t<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:\u00a0<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normal findings might be documented as: \u201cNails are smooth, firm, clean with translucent colour, and no presence of clubbing. Capillary refill within 2 seconds.\u201d<\/span><\/li>\r\n \t<li><span style=\"color: #000000;text-align: initial;font-size: 1em\">Abnormal findings might be documented as: \u201cNail angle on thumbs is slightly greater than 180 degrees, capillary refill time is 5 seconds.\u201d<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Nail concerns do not usually require immediate intervention. However, a client with sluggish capillary refill combined with other cues suggesting severely reduced blood flow to the limbs requires additional interventions to re-establish blood flow. For example, if associated with absent or diminished pulses, cool limbs, numbness, cyanosis, or pallor, report these findings to the physician or nurse practitioner.\u00a0<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Some other nail concerns also may need to be addressed promptly. For example, nail [pb_glossary id=\"1249\"]laceration[\/pb_glossary], [pb_glossary id=\"1250\"]avulsion[\/pb_glossary], and [pb_glossary id=\"1251\"]subungual hematoma[\/pb_glossary] may require treatment. Bleeding under the nail can cause pressure and pain, and drilling a small hole in the nail can alleviate the pain associated with pressure by allowing the blood to escape the nail bed. With some cases of laceration and avulsion, healthcare providers may need to remove or glue the nail or the surrounding skin may need to be stitched in place.\u00a0<\/span><\/p>\r\n\r\n<\/div>\r\n<\/div>","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\">Inspection and palpation of nails can be accomplished with the client in a sitting upright position or lying supine. Nail polish or artificial nails must be removed to fully assess the nails. You will need to decide if a full nail assessment is warranted depending on the nature of the visit, the reason for seeking care and the client\u2019s status. If appropriate, remind the client to arrive without nail polish or artificial nails before their appointment.\u00a0<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Steps for nail inspection and palpation include:<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Inspect the nail condition<\/strong> and <strong>nail colour<\/strong> by asking the client to hold their hands out in front of them (<strong>Figure 10<\/strong>).<\/span><\/li>\n<\/ol>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-300x200.jpg\" alt=\"Nurse inspecting client's nail condition.\" class=\"alignnone wp-image-1253\" width=\"427\" height=\"284\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-300x200.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-1024x683.jpg 1024w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-768x512.jpg 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-1536x1024.jpg 1536w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-2048x1365.jpg 2048w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-65x43.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-225x150.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/DSC00122-350x233.jpg 350w\" sizes=\"auto, (max-width: 427px) 100vw, 427px\" \/><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 10<\/strong>: Inspection of nails. <\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">(Licensed under a Creative Commons Attribution-Non-commercial 4.0 License. Arthur Labatt Family School of Nursing, &#8220;Nail Colour Assessment&#8221; (2021). Respiratory Exams. <\/span><a href=\"https:\/\/ir.lib.uwo.ca\/clinicalskills_respexam\/15\" target=\"_blank\" rel=\"noopener\">https:\/\/ir.lib.uwo.ca\/clinicalskills_respexam\/15<\/a><span style=\"color: #000000\">)<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Normally, the ends of the nails are smooth and nails are clean. A client\u2019s job may influence nail cleanliness. Nails are translucent in colour and have a slight pinkish tone. <\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Abnormal findings may include ridges, pitting, brittleness, indentations, and discolourations. If you note any abnormal nail condition or discolouration, describe the appearance and location, e.g., white markings at the base of the nail on the left index finger. <strong>Table 9<\/strong> lists some nail variations that you may observe. Yellowing or darkening of the nails is a common discolouration associated with nail fungus (see <strong>Figure 11<\/strong>)<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p style=\"text-align: left\"><span style=\"color: #000000\">Landmark digits (fingers and toes) appropriately. Many institutions have a body diagram to landmark anatomy. Check with your institution for specific nomenclature, which can vary in terms of how digits are referenced. Sometimes the thumb as referred to as Digit 1, index finger as Digit 2, middle finger as Digit 3, ring finger as Digit 4, and little finger as Digit 5. If you are uncertain about how to reference a specific digit, landmark as descriptively as possible (e.g., middle finger left hand, 2nd medial toe right foot).\u00a0<\/span><\/p>\n<\/div>\n<\/div>\n<p><span style=\"color: #000000\"><strong>Table 9:<\/strong> Nail colour changes.<\/span><\/p>\n<div style=\"text-align: left;\">\n<table class=\"grid\">\n<tbody>\n<tr class=\"shaded\">\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Colour Variation<\/strong><\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Description<\/strong><\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">White<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Loss of pigmentation (pinkness) and whitening of the nail bed can be the result of lack of perfusion related to illnesses like diabetes and liver disease.\u00a0<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Blue<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Blue hue of the nail bed can be an indication of hypoxia.\u00a0<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Yellow<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Yellowing of the nails can be a sign of chronic lung disease or lymphedema: over time, the nails thicken and become yellow due to lack of drainage of lymph fluid under the nail bed. Yellowing can also be a sign of rheumatoid arthritis or fungal infection. Smoking can also discolour the nail and leave yellow nicotine stains.\u00a0<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Red\/brown half-moons<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Red half-moons may be a sign of auto-immune disorder.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Blue half-moon<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">A blue-half moon is a sign of poisoning (e.g., silver).\u00a0<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Black stripe<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">A black stripe that runs down the nail bed can be a sign of melanoma, but also can be benign.\u00a0<\/span><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"vertical-align: top;width: 264.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Greenish black<\/span><\/p>\n<\/td>\n<td style=\"vertical-align: top;width: 584.988px\">\n<p class=\"no-indent\"><span style=\"color: #000000\">Bacterial infection under the nail can cause a greenish black appearance (see <strong>Figure 11<\/strong>).\u00a0<\/span><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-225x300.jpg\" alt=\"A person's right foot. The big toe is discoloured at the base with a line down the middle which is nail fungus.\" class=\"alignnone wp-image-1255 size-medium\" width=\"225\" height=\"300\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-225x300.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-768x1024.jpg 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-1152x1536.jpg 1152w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-1536x2048.jpg 1536w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-65x87.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-350x467.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-Nail-fungus-RL-scaled.jpg 1920w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/> <img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-225x300.jpg\" alt=\"A person's left foot. The big toe is yellowish in colour and has nail fungus.\" class=\"alignnone wp-image-1256 size-medium\" width=\"225\" height=\"300\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-225x300.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-768x1024.jpg 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-1152x1536.jpg 1152w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-1536x2048.jpg 1536w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-65x87.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-350x467.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2022\/12\/Figure-10-nail-fungus-IMG_0958-scaled.jpg 1920w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 11:<\/strong> Nail fungus.<\/span><\/p>\n<ol start=\"2\">\n<li><span style=\"color: #000000\"><strong>Assess for the presence of clubbing<\/strong> (see <strong>Figure 12<\/strong>\u00a0and <strong>Video 4 <\/strong>and <b>5<\/b>). Clubbing is related to conditions that lead to chronic hypoxia (e.g., chronic lung diseases, cystic fibrosis, congenital heart disease). Chronic hypoxia can cause the nail angle to flatten to 180 degrees or more, the nail bed to soften and become spongy, and the fingertips distal to the distal interphalangeal joint to become enlarged. Clubbing typically first develops in the thumb and then the forefingers. It is often assessed on the index finger, but in cases of early clubbing it may not have advanced to that digit, so it is best to assess the thumb first. To assess for the presence of clubbing, ask the client to point their thumb out so that it is parallel to the ground and view it at your eye level (this is considered the profile sign). Inspect the nail angle at the intersection of where the nail base meets the skin.<br \/>\n<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\">Normally, the nail angle base is about 160 degrees with normal-sized fingertips and nail beds that are firm to touch.<\/span><\/li>\n<li><span style=\"color: #000000\">Clubbing is evident when the angle of the nail base is greater than 180 degrees (flattening of the nail base); fingertips are usually enlarged and bulb-like, and the nail base is spongy\/soft upon palpation.\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-1024x768.jpeg\" alt=\"Two hands showing bulbed-like fingertips.\" width=\"450\" height=\"338\" class=\"alignnone wp-image-1531\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-1024x768.jpeg 1024w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-300x225.jpeg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-768x576.jpeg 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-1536x1152.jpeg 1536w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-2048x1536.jpeg 2048w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-65x49.jpeg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-225x169.jpeg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-content\/uploads\/sites\/367\/2023\/01\/Clubbing_of_fingers-350x263.jpeg 350w\" sizes=\"auto, (max-width: 450px) 100vw, 450px\" \/><\/strong><\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 12:<\/strong> Clubbing.<\/span><\/p>\n<p>(Photo by Sidsandyy, CC BY-SA 3.0, <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=40100295\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=40100295<\/a>)<\/p>\n<p>&nbsp;<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Inspection for Clubbing (Index) - Integumentary System Chapter\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/aZOQQOWX1wU?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"color: #000000\"><strong>Video 4<\/strong>: Inspection for clubbing on the index finger [0:19]<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-3\" title=\"Inspection for Clubbing (Thumb) - Integumentary System Chapter\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/g-GgVvSvsJk?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 5:<\/strong> Inspection for clubbing on the thumb [0:18]<\/span><\/p>\n<ol start=\"3\">\n<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\"><strong>Palpate the nails for texture and consistency<\/strong> using a grasping motion: place the pad of your index finger on the client\u2019s nail and your thumb on the underside of the client\u2019s finger. Palpate the whole nail including the nail bed.<\/span><span style=\"color: #000000\"><br \/>\n<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\">Normally, nails are smooth and firm.<\/span><\/li>\n<li><span style=\"color: #000000\">Describe the appearance and location of thick nails and spongy\/soft nails.<br \/>\n<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol start=\"4\">\n<li><span style=\"color: #000000\"><strong>Palpate the nails for capillary refill<\/strong> on two or three fingernails of each hand, at heart level (see <strong>Video 6<\/strong>). Start by applying pressure with your own finger to the client\u2019s nail; this causes the nail to blanch (become paler in colour). Apply the pressure for 5 seconds and then release and observe the return in colour.<br \/>\n<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\"><span style=\"font-size: 1em\">A normal finding when assessing capillary refill is colour return within 3 seconds or less.<\/span><\/span><\/li>\n<li><span style=\"color: #000000\">Colour return taking longer than 3 seconds is considered sluggish return for capillary refill (or slow capillary refill time), and this finding suggests possible issues with <button class=\"glossary-term\" aria-describedby=\"1043-1829\">oxygenated blood perfusion<\/button> (this may be related to peripheral vascular and\/or cardiac and\/or respiratory issues). Note that capillary refill time can be slower if the client\u2019s hands are cold from being outside or from washing in cold water; ask them to warm their hands to ensure an accurate reading.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" id=\"oembed-2\" title=\"Capillary Refill Test Video - Peripheral Vascular Chapter\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/CXGN89Bkl-0?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 6:<\/strong> Capillary refill [0:45]\u00a0<\/span><\/p>\n<ol start=\"5\">\n<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:\u00a0<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\">Normal findings might be documented as: \u201cNails are smooth, firm, clean with translucent colour, and no presence of clubbing. Capillary refill within 2 seconds.\u201d<\/span><\/li>\n<li><span style=\"color: #000000;text-align: initial;font-size: 1em\">Abnormal findings might be documented as: \u201cNail angle on thumbs is slightly greater than 180 degrees, capillary refill time is 5 seconds.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p style=\"text-align: left\"><span style=\"color: #000000\">Nail concerns do not usually require immediate intervention. However, a client with sluggish capillary refill combined with other cues suggesting severely reduced blood flow to the limbs requires additional interventions to re-establish blood flow. For example, if associated with absent or diminished pulses, cool limbs, numbness, cyanosis, or pallor, report these findings to the physician or nurse practitioner.\u00a0<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Some other nail concerns also may need to be addressed promptly. For example, nail <button class=\"glossary-term\" aria-describedby=\"1043-1249\">laceration<\/button>, <button class=\"glossary-term\" aria-describedby=\"1043-1250\">avulsion<\/button>, and <button class=\"glossary-term\" aria-describedby=\"1043-1251\">subungual hematoma<\/button> may require treatment. Bleeding under the nail can cause pressure and pain, and drilling a small hole in the nail can alleviate the pain associated with pressure by allowing the blood to escape the nail bed. With some cases of laceration and avulsion, healthcare providers may need to remove or glue the nail or the surrounding skin may need to be stitched in place.\u00a0<\/span><\/p>\n<\/div>\n<\/div>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"1043-1829\" hidden><p>refers to the flow of blood that is oxygenated to the body's tissues such as the legs.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"1043-1249\" hidden><p>is a cut or tear in the nail.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"1043-1250\" hidden><p>is when the nail is lifted off the nail bed either partial or completely.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"1043-1251\" hidden><p>is bleeding under the nail.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":8,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-1043","chapter","type-chapter","status-publish","hentry"],"part":995,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/1043","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":33,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/1043\/revisions"}],"predecessor-version":[{"id":1830,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/1043\/revisions\/1830"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/parts\/995"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapters\/1043\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/media?parent=1043"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/pressbooks\/v2\/chapter-type?post=1043"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/contributor?post=1043"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing2\/wp-json\/wp\/v2\/license?post=1043"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}