Skin Assessment
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Transcript of Skin Assessment
Skin Assessment
Skin is the largest organ in the body Skin is composed of
1. Epidermis- outermost portion of a relatively uniform, thin but tough, composed of thickness stratum germinativum and stratum corneum
◦ a. color derived from three sources Brown- pigment melanin Yellow-orange tones of pigment carotene Red-purple tone in underlying vascular bed
Skin Assessment
2 .Dermis- bulk of skin; the inner supportive layer
consisting mostly of connective tissue or collagen
is tough fibrous protein that enables skin to resist
tearing and allows skin to stretch with movement.
3 .Subcutaneous layer- adipose tissue made up of
lobules of fat cells used for energy. It provides
insulation for temperature control and aids in
protection by its soft cushioning effect
Skin function
• Protection/Barrier• Sensation• Temperature regulation• Identification• Communication• Wound Repair• Absorption/Excretion• Vitamin D
1. Previous history of skin diseases2. Skin Color- affected by genetic factors and
physiological factors. -Variations of skin color
• Cyanosis- blue tinge• Pallor- loss of rosy glow in skin, paleness• Erythema- redness of the skin, increase in
climate temperature, inflammation, infection
Assess Skin of Adults
• Plethora- redness of skin caused by increase red blood cell
• Ecchymosis- large diffuse areas usually black and blue , results of injuries
• Petechiae- small pinpoint hemorrhages can denote some type of blood disorder
• Jaundice- yellow staining of skin usually caused by bile pigments
3. Changes in mole • size, shape, tenderness, bleeding• check for abnormal characteristics of
pigmented lesions. • Note any freckles and changes and any
birthmarks (report any changes in size, itching, burning, bleeding of moles)
Abnormal characteristics of pigmented lesions:
ABCDE• Asymmetry of pigmented lesion -one that
is not regularly round or oval• Border irregularity -notching,
scalloping, ragged edges or poorly defined margins
• Color variation -areas of brown, tan, black, blue, red, white or combination
• Diameter greater than 6mm• Elevation and enlargement
4. Texture- palpate note any marks or scaring
skin should be smooth and firm
5. Temperature- symmetrically feel each part of
the body, compare upper area with lower areas
check for hypothermia and hyperthermia• Normal finding: warm• Changes: cool, cold, hot
6. Turgor-amount of elasticity in skin, grasp index finger pull it taut and quickly release- elastic skin immediately assumes in normal position, poor turgor suspended or tented; turgor shows hydration and nutrition
7. Moisture or dryness- check face, hands, axilla, skin folds; shows diaphoresis or dehydration
8. Are there any rashes or lesions; note color, elevation, pattern or shapes, size, location and distribution on body, any exudates
9. Is there any itching (purities)10. What medication are you taking11. Note mobility12. Note any edema- accumulation of fluid in the
intercellular spaces; to check for edema, imprint your thumbs firmly against the ankle malleolus or the tibia. If pressure leaves a dent in the skin “pitting” present
1=+ mild pitting, slight indentation, no perceptible swelling of the leg
2=+ moderate pitting, indentation subsides rapidly
3=+ Deep pitting, indentation remains for a short time; leg looks swollen 4=+Very Deep pitting, indentation
lasts a long time, leg is very swollen.
13.thickening uniform over body except thick over palms and soles of feet
Edema
Pitting edema
Assessing for Edema• Depress
pretibial area & medial malleolus for 5 seconds
• Grade pitting edema1 +to 4+
1. Hair- ◦ inspect for color (comes from melanin) graying may
begin at 3rd decade; ◦ Texture maybe fine or thick; straight, curly, or kinky;◦ Quality maybe shinny or dull;◦ Distribution- coarse or elastic
2. Scalp- inspect for ticks or lice3. Nails- Shape and Contour- curved or flat,
edges smooth, rounded, clean; - Consistency- smooth, regular, nor brittle or splitting,
thickness, firm - Color- translucent, pink nails base
- inspect nail beds for clubbing
Accessory structure of skin of adults
• Capillary return or refill: normal = less than 3 seconds– used to evaluate the ability of the circulatory system to restore
blood to the capillary system (perfusion).– Capillary refill is evaluated at the nail bed in a finger.
(a)Place your thumb on the patient’s fingernail and gently compress. (b)Pressure forces blood from the capillaries. (c)Release the pressure and observe the fingernail. (d) As the capillaries refill, the nail bed returns to its normal deep
pink color. (e)Capillary refill should be both prompt and pink. (f) Color in the nail bed should be restored within 2 seconds, about
the time it takes to say "capillary refill."
• Check color• Temperature• Abnormalities• Excessive dryness, moisture, itching, flaking• General texture of skin• Skin turgor• Edema• Cleanliness• Odor• Discoloration (ecchymosis, petechiae, purpura,
erythema, altered pigmentation)
Monitoring Skin Condition
Vocabulary
– Alopecia– Hirsutism– Clubbing of nail– Onycholysis
Benefits and Disadvantages
☺ •Quick
•Inexpensive •Can be done ‘on-site’
•Valid for all visibleskin conditions
• Subjective, noquantitative data• Requiresexperience/training• May not indicate subclinicaldamage• Surface conditions donot always correlatewith conditions in the
• Go to this website for a tutorial on skin assessment
• http://www.logicalimages.com:80/morphology/morphology3_content.html
Practice