Skin Assessment

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Skin Assessment

• Peggy Korman, CNM
• NRS 320
• Foundations of Nursing Practice

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Integumentary System

• Nails
• Hair
• skin

3
Assessment Techniques

• Inspection
• Palpation
• Olafactory

4
Functions of the Skin

• Bodys External Protector
• Regulation of body temperature
• Sensory organ for pain, temperature, touch

5
Skin Assessment

• Normal skin color is consistent with genetic
  background
• Variations indicate some kind of problem
• It is important to identify probable causes for
  skin to change its appearance
• Skin is assessed for temperature, color,
  moisture, turgor, texture

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Skin Assessment

• Color normal skin color is consistent with
  genetic background. Variations that indicate
  problems include pallor, erythema, cyanosis and
  jaundice
• Document the patients color as
• Normal
• Pale
• Cyanotic
• Flushed
• jaundiced

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What can cause these color changes?

• Pallor
• Eythema
• Jaundice
• Cyanosis

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What can cause these color changes?

• Pallor anxiety, anemia
• Erythema carbon monoxide poisoning
• Jaundice cirrhosis
• Cyanosis hypoxemia

9
Assessing Dark-Skinned Patients

• No matter what a patients race or ethnicity, the
  ability to note changes in skin color can mean
  life or death. Assessment can be difficult or
  inaccurate if you are unfamiliar with highly
  pigmented skin tones.

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Assessing Dark-Skinned Patients

• Adequate lighting-daylight is best
• Establish a baseline for skin tone by observing
  least pigmented areas (palms, soles of feet,
  buttocks, volar surfaceof forearm, mouth,
  conjunctiva, nail beds)
• Look for underlying reddish tone common to all
  skin

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Skin Temperature

• Temperature and other characteristics
• Warm and dry?
• Cool and clammy?
• Diaphoretic?
• Lesions? Wounds?
• Normal ASsessment
• Color normal, warm, dry and intact

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What can cause these temperature changes?

• Generalized coolness
• Generalized warmth
• Localized coolness
• Localized hyperthermia

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What can cause these temperature changes

• Generalized coolness Hypothermia or cool down
  from OR
• Generalized warmth Fever or increased metabolic
  rate
• Localized coolness Poor circulation in the area,
  casts
• Localized hyperthermia Infection, cut or surface
  wound

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Assessing Moisture

• Abnormal Skin Moisture
• Diaphoresis may accompany chest pain, fever,
  anxiety
• Dryness may present as dehydrated lips,
• or as dry or cracked mucus membranes
• Oiliness often causes acne

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Assessing Texture

• Skin may be rough, dry, scaly, thick
• Skin may be very smooth, thin and moist (but not
  necessarily oily)
• Red, scaly patches may indicate eczema (in
  infants may appear on cheeks or in diaper area)
• Cradle cap manifests as greasy, yellow-brown
  patchs on scalp when not properly washed

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Thyroid conditions

• Hyperthyroidis Hypothyroidis
• smooth dry
• moist thick
  
• warm pale
• thin rough scaly
• itchy

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Wound Assessment

• Wound
• Type incision,laceration, skin tear,
  rash,perineal excoriation, decubitus
• Appearance pink, red, eschar, sloughing,edematous
  , ecchymosis
• Dressing open to air, changed, sterile, dry,or
  intact with sutures, staples, steristrips
• Drainage serous, purulent, sanguinous, or none

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Wounds with Eschar
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Incisions
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Bruising/Ecchymosis

• Ecchymosis should be consistent with reported
  trauma. Bruising above the knees and below the
  elbows is suspicioius and may indicate abuse.
• Photograph ecchymosis (ED)
• The age of the ecchymosis can be determined by
  color

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Assessing Skin Turgor

• To determine turgor, pinch a fold of skin under
  the clavicle or on the forearm so the top skin
  separates from the underlying structure. Assess
  as follows
• Normal rises easily and returns to place
  immediately
• Abnormal skin does not return to place
  immediately but exhibits tenting

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Assessing Turgor

• Because poor skin turgor is more common and more
  prominent in the elderly patient due to loss of
  elasticity, check for skin turgor at the sternum.
• Abnormal turgor is exhibited in dehydration,
  edema, scleroderma, connective tissue disorders

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Assessing Lesions

• Examine lesion color and elevation with a
  flashlight
• Wear gloves to examine lesions
• Record size (diameter) of lesions and surrounding
  erythema in centimeters

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Assessing Lesions

• Elevation
• Flat?
• Raised?
• Pedunculated (connected to the skin on a stem or
  stalk-like base)

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Assessing Lesions

• Distrubution Symmetrical or asymmetrical
  distribution of lesions
• Generalized (widely distributed)
• Localized
• Regional (specific to an area)

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Assessing Pressure Ulcers
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Stage One

• Intact skin with non-blanchable redness of a
  localized area usually over a bony prominence

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Stage Two

• The epidermis or topmost layer of the skin is
  broken, creating a shallow open sore. Drainage
  may or may not be present.

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Stage Three

• Full thickness tissue loss. Subcutaneous fat may
  be visible but muscle, bone and tendon are not
  exposed. Slough may be present but does not
  obscure the depth of the tissue loss. May
  include undermining and tunneling.

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Stage Four

• Full thickness skin loss with extensive
  destruction, tissue necrosis, or damage to
  muscle, bone, or supporting structures.

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Assessing IV Site

• Note if IV is patent
• Note location and type of catheter
• Note if there is redness or edema
• Note if the dressing is dry and intact
• Note if IV site or dressing is changed