Skin Assessment :Skin Assessment Staff Development Nursing Education


Integumentary System :Integumentary System Nails Hair Skin


Assessment Techniques :Assessment Techniques Inspection Palpation 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: Normal Pale Cyanotic Flushed Jaundiced


What can cause these color changes? :What can cause these color changes? Pallor Erythema Jaundice Cyanosis Anxiety, Anemia Carbon Monoxide poisoning Cirrhosis 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? Diaphoretic? Lesions? Wounds? Normal Assessment Color normal, warm, dry and intact.


What can cause these temp changes? :What can cause these temp changes? Generalized coolness Generalized warmth Localized 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 smooth warm moist thin Hypothyroidism dry thick itchy 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 Flat? Raised? Pedunculated (connected to the skin on a stem or stalk-like base?


Assessing Lesions :Assessing Lesions Distribution Symmetrical or Asymmetrical distribution? Generalized? (widely distributed) Localized 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 (1.3 hours) The Health History, and Anatomy and Physiology Assessing Skin Color Assessing Lesions Skin Tumors and Pressure Ulcers Hair and Nails


Thank you. :Thank you.