Joy N.

Bautista, RN, MPH, DRDM, MAN

Skin Assessment

Health History: SKIN

How and when did the skin changes occur? Rash or lesion? Confined to one area, or has spread? Bleeds or has drainage? Itch? Time spent in the sun? Protection of skin from ultraviolet rays?

Health History: SKIN

Allergies? Family history of skin cancer or other significant diseases? Fever or joint pain, weight loss? Recent insect bite? Medications or herbal preparations? Changes in the skin observed in the past few years?

Health History: SKIN

(For pediatric patients, ask parents) Any birthmarks? Experience of any change in skin cyanosis or jaundice? Rashes, burns, or bruises? Where and when, and what was the cause? Exposure to any contagious skin conditions such as scabies, lice, or impetigo or communicable diseases?

Health History: HAIR

When? Hair loss or gain? Sudden or gradual? A few spots or all over body? Related life events when problem started? Any medications or herbal preparations? Itching, pain, discharge, fever, or weight loss? History of serious illness?

Health History: NAILS

When? Types of changes? Nail shape, color, or brittleness? Sudden or gradual? Other signs or symptoms, such as bleeding, pain, itching, or discharge? Normal condition or your nails? History of serious illness? History of nail problems? Bite nails? Nail tips attached?

Physical Exam: TOOLS

a clear ruler with centimeter and millimeter markings a tongue blade a penlight or flashlight a magnifying glass

Physical Exam: SKIN COLOR

Cyanosis - dull, bluish-dark color Edema - decreased color Erythema - palpate the area for warmth. Jaundice - yellowish color Pallor - ashen color Petechiae - tiny, purplish red dots in areas that are light colored (abdomen) Rashes - skin gesture changes Mongolian spots irregularly shaped bluish discoloration in buttocks

Mongolian spots

Jaundice

Pallor

Cyanosis

Erythema

Physical Exam: SKIN TEXTURE & TURGOR

Texture Smooth and intact Rough, dry skin hypothyroidism, psoriasis, and excessive keratinization Turgor Good Poor - dehydration and edema cause poor skin turgor Edema Overhydration

Physical Exam: SKIN MOISTURE

Relatively dry, with a minimal amount of perspiration. Skin-fold areas fairly dry. Overly dry skin appears red flaky. Overly moist skin - anxiety, obesity, or an environment thats too warm. Heavy sweating, or diaphoresis - fever, strenuous activity; cardiac, pulmonary, and other diseases; and any activity or illness that elevates metabolic rate.

Physical Exam: SKIN TEMPERATURE

Palpate the skin bilaterally for temperature Warm skin suggests normal calculation Localized warmth local areas that are infected, inflamed, or burned Generalized warmth - fever or systemic diseases such as hyperthyroidism Cool skin Localized - vasoconstriction associated with cold environment or impaired arterial circulation to a limb Generalized - shock or hypothyroidism

Physical Exam: SKIN LESIONS

Red lesions - caused by vascular changes
Telangiectases - permanently dilated, small blood vessels that typically form a weblike pattern Purpura - caused by red blood cells and blood pigments in the skin; dont blanch under pressure Petechiae - red or brown lesions generally caused by capillary fragility; d/t endocarditis, thrombocytopenia Ecchymoses - bluish or purplish discolorations d/t blood accumulation in the skin after injury to the vessel wall Hematomas - masses of blood that accumulates in a tissue, organ, or body space after a break in a blood vessel

Normal variations
Birthmarks - generally flat and range in color from tan to red or brown Freckles - small, flat red-brown to brown macules located primarily on the face, arms, and back Nevi - either flat or raised, pink, tan, or dark brown

Physical Exam: SKIN LESIONS

Primary lesion new Secondary lesion - changes in a primary lesion Fissures Scales Crusts Scars Excoriations

Physical Exam: SKIN LESIONS

Macule Flat, circumscribed area of altered skin color Generally less than 3/8 (1 cm) Example = freckle, flat nevus Papule Raised, circumscribed, solid area Generally less than 3/8 Examples: elevated nevus, wart Vesicle Circumscribed, elevated lesion Contains serous fluid Less than 3/8 Example: early chickenpox.

Macule

Papule

Vesicle

Cafe-au-lait

Spider nevi

Telangiectasis

Hematoma

Physical Exam: SKIN LESIONS

Solid - macules, papules, nodules, wheals, and hives Fluid-filled - vesicles, bullae, pustules, and cysts Macule vs papule Reduce direct lighting and shine a penlight or flashlight at a right angle to lesion If the light casts a shadow, the lesion is a papule Solid vs fluid-filled Place the tip of a flashlight or penlight against the side of the lesion Fluid-filled lesions transilluminate with a red glow

Physical Exam: SKIN LESIONS

Characteristics, pattern, location, and distribution Changes in size- increase in the size or elevation Take note of moles the rapidly change size, especially moles that are 6 mm or larger Note drainage, document the type, color, and amount Note if the lesion has a foul odor, which can indicate a superimposed infection.

Physical Exam: SKIN LESIONS

Confluent

Discrete

Grouped

Linear

Annular

Arciform

Polycyclic

Reticular

Physical Exam: HAIR

Inspect and palpate the hair over the patients entire body, not just on his head. Note the distribution, quantity, texture, and color. Check for patterns of hair loss and growth. Examine the scalp for erythema, scaling, and encrustation Note areas of excessive hair growth Note the texture of scalp hair Shiny and smooth Dry or brittle Extreme oiliness

Physical Exam: NAILS

Assess color of the nails Pinkish - Light-skinned people Brownish - Dark-skinned people Yellow nails - Smokers because of nicotine stains Assess nail beds to estimate patients peripheral circulation Normal capillary refill time (CRT) < 2 secs Inspect the shape and contour of the nails The surface of the nail bed should be either slightly curved or flat The edges of the nail should be smooth, rounded, and clean The angle of the nail base is normally less than 180 degrees Palpate the nail bed to check the thickness of the nail and the strength of its attachment to the bed.