NURS-330: Management of Care 1 (Exam 3)

What are the two primary techniques used in a skin assessment?

Inspection and palpation

What should be included in a comprehensive skin inspection?

Color, texture, moisture, and integrity of the skin

What does palpation assess during a skin exam?

Texture, moisture, temperature, mobility, and turgor

What are key components of a health history related to skin assessment?

• Skin disease/cancer history

• Changes in moles/pigmentation

• Excessive dryness/moisture

• Pruritus

• Bruising

• Rashes/lesions

• Medications and allergies

• Environmental exposures

A patient’s skin holds information about their…

Circulation, nutritional status, and signs of systemic diseases

What is considered normal skin color?

Even and consistent with genetic background

What are examples of expected variations of skin color?

• Freckles

• Birthmarks

• Scars

• Wrinkles

What is vitiligo?

Loss of skin pigmentation resulting in patchy white areas

What are examples of unexpected variations of skin color?

• Pallor

• Erythmea

• Cyanosis

• Jaundice

• Ecchymosis

What does pallor indicate?

Pale/white skin

Where should pallor be assessed?

Lips, mucous membranes, and nail beds

What is erythmea?

Redness due to inflammation

How does erythmea appear in darker skin tones?

It may appear purplish

What is the difference between blanchable and non-blanchable erythmea?

Blanchable erythmea turns white with pressure (temporarily); non-blanchable does not change (possible tissue damage/pressure injury)

What is cyanosis?

Blue discoloration

Why is cyanosis harder to detect in dark skin tones?

It appears as a dull or darker undertone rather than blue

A nurse suspects cyanosis in a dark-skinned patient. Where should the nurse assess?

Oral mucosa and nail beds

What is jaundice?

Yellowing of the skin

Where is jaundice best visualized in light skin?

Sclera and hard palate

Where is jaundice best visualized in dark skin?

Palms and soles

What is eccymosis and how does it change over time?

Bruising that changes color as it heals (red → purple → yellow/green)

What is normal skin texture and moisture?

Smooth and uniformly dry

What are examples of expected variations of skin texture/moisture?

• Xerosis

• Seborrhea

• Acne

• Wrinkles

• Scars

• Stretch marks

• Keloid

What is xerosis?

Dry skin due to decreased oil production

What is seborrhea?

Excessively oily skin

What are examples of unexpected variations of skin texture/moisture?

• Velvety

• Dry/flaky

• Diaphoresis

What does velvety skin indicate?

Possible thyroid disease

What can rough, flaky skin indicate?

Dehydration or thyroid disorder

What is diaphoresis?

Excessive sweating (often abnormal)

What defines normal skin integrity?

Skin that is smooth and intact

What defines abnormal skin integrity?

Presence of lesions

What should the nurse document when assessing a lesion?

• Color

• Height

• Shape

• Size

• Location

• Drainage

What are types of skin lesions?

• Vascular (petechiae, ecchymosis, purpura)

• Primary

• Secondary

____________ result from blood leaking from blood vessels into the dermis.

Vascular lesions

____________ are the result of a specific triggering agent that causes a change to previously intact skin.

Primary lesions

____________ are lesions that evolved from their original state as primary lesions; the passage of time changes their characteristics.

Secondary lesions

What are moles?

Clumps of melanocytes; acquired nevi have symmetry, small size (<6 mm), smooth borders, and single uniform pigmentation

What are warning signs of malignant moles (ABCDEF)?

• Asymmetry

• Border irregularity

• Color variation

• Diameter >6 mm

• Elevation

• “Funny-looking”

What are the expected findings for skin temperature?

Skin should feel warm

What are some unexpected findings for skin temperature?

Hypothermia and hyperthermia

What indicates normal skin turgor?

Skin rises easily and quickly returns to place after being pinched

What is an expected age-related change in skin turgor?

Slight delay in recoil

What are some unexpected variations of skin turgor?

Tenting and edema

A nurse notes skin remains elevated after pinching. What is the priority interpretation?

Dehydration

What are expected nail assessment findings?

• Curved or flat nails

• Smooth, rounded edges

• Translucent color

• Capillary refill <2 seconds

What is an expected age-related change in nails?

What are unexpected nail assessment findings?

What is an example of proper skin and nail documentation?

“Skin tan-pink, warm, dry, smooth, elastic turgor; no lesions. Nails pink with cap refill <2 sec.”