Skin Assessment : Skin Assessment Staff Development
Nursing Education Integumentary System : Integumentary System Nails
Skin Assessment Techniques : Assessment Techniques Inspection
Olfactory Functions of Skin : Functions of Skin Body’s external protector
Regulation of body temperature
Sensory organ for pain, temperature, and touch Skin Assessment : Skin Assessment Normal skin color is consistent with genetic background.
Variations indicate some type of problem.
It is important to identify probable causes for skin to change its appearance.
Skin is assessed for color, temperature, moisture, texture and turgor. Skin Assessment : Skin Assessment Color - Normal skin color is consistent with genetic background. Variations that indicate problems include pallor, erythema, cyanosis and jaundice.
Document the patient’s color as:
Jaundiced What can cause these color changes? : What can cause these color changes? Pallor
Cyanosis Anxiety, Anemia
Carbon Monoxide poisoning
Hypoxemia Assessing Dark-Skinned Patients : Assessing Dark-Skinned Patients No matter what a patient’s 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. Assessing Dark-Skinned Patients : Assessing Dark-Skinned Patients Adequate lighting - daylight is best
Establish a baseline for skin tone by observing least pigmented areas (palms, soles of feet, abdomen, buttocks or volar surface of forearm, also mouth, conjunctiva and nail beds.)
Look for underlying reddish tones common to all skin Skin Assessment : Skin Assessment Temperature and other characteristics
Warm and dry?
Cool and clammy?
Color normal, warm, dry and intact. What can cause these temp changes? : What can cause these temp changes? Generalized coolness
Localized hyperthermia Hypothermia (shock or cool down for OR)
Fever or increased metabolic rate (Flu)
Poor circulation in the area (Casts)
Infection (cut or surface wound) Assessing Moisture : Assessing Moisture Abnormal Skin Moisture
Diaphoresis may accompany anxiety, fever, chest pain
Dryness may present as dehydrated lips, or as dry and cracked mucous membranes
Oiliness often causes acne Assessing Texture : Assessing Texture Skin may be rough, scaly, dry, or 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 diaper area)
Cradle cap manifests as greasy, yellow-brown patches on scalp when not properly washed Thyroid Conditions : Thyroid Conditions Hyperthyroidism
rough and scaly
pale Wound Assessment : Wound Assessment Wound
Type: incision, laceration, skin tear, rash, perineal excoriation or decubitus
Appearance: Pink, red, eschar, sloughing, edematous, ecchymosis
Dressing: Open to air, changed, sterile, dry, or intact with staples,sutures or steri-strips
Drainage: Serous, purulent, sero-sanguinous, or none Bruising / Ecchymosis : Bruising / Ecchymosis Ecchymosis should be consistent with reported trauma. Bruising above the knees and below the elbows is suspicious and may indicate abuse.
Photograph ecchymosis (ER)
The age of the ecchymosis can be determined by color Assessing Skin Turgor : 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 immediately return to place but exhibits “tenting” Assessing Skin Turgor : Assessing Skin Turgor Assessing Skin Turgor : Assessing Skin Turgor Because poor turgor is more common and more prominent in elderly patients due to loss of elastic tissue, check for skin turgor at the sternum.
Abnormal turgor is exhibited in
? edema ? dehydration ? scleroderma ? connective tissue disorders Assessing Lesions : Assessing Lesions Examine lesion color and elevation with a flashlight
Wear gloves to examine lesions
Record size (diameter) of lesion and surrounding erythema in centimeters. Assessing Lesions : Assessing Lesions Elevation
Pedunculated (connected to the skin on a stem or stalk-like base? Assessing Lesions : Assessing Lesions Distribution
Symmetrical or Asymmetrical distribution?
Generalized? (widely distributed)
Regional (specific to an area) Assessing Pressure Ulcers : Assessing Pressure Ulcers Stage One : Stage One Stage One
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage Two : Stage Two The epidermis or topmost layer of the skin is broken, creating a shallow open sore. Drainage may or may not be present. Stage Three : Stage Three Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Stage Four : Stage Four Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting Assessing IV Sites : Assessing IV Sites IV site:
Note if IV is patent
Note location and type of intracath
Note if there is redness or edema
Note if the dressing is dry and intact
Note if IV site or dressing is changed Further information found on .edu : Further information found on .edu Assessment of the Integumentary System
The Health History, and Anatomy and Physiology
Assessing Skin Color
Skin Tumors and Pressure Ulcers
Hair and Nails Thank you. : Thank you.