Skin

Assessment

The process of inspecting and palpating the skin to evaluate its color, texture, moisture, integrity, and other characteristics.

Functions

The various roles of the skin, including protection from the environment, perception of stimuli, maintenance of homeostasis, identification, wound repair, secretion, excretion, and absorption.

Color

The natural pigmentation of the skin, which can vary from whitish pink to light or dark brown, yellow, or olive tones. Higher vessel supply can result in a more red color, particularly on the cheeks and chest. Darker skin tones may have a lighter tone on their palms and feet.

Hyperpigmentation

Darkening of the skin due to an increase in melanin production. Examples include freckles, chloasma, age spots, and tan lines.

Hypopigmentation

Lightening of the skin due to a decrease in melanin production. Examples include scars, stretch marks, and vitiligo.

Jaundice

A yellow tint to the skin caused by an excess of bilirubin, which is a byproduct of the breakdown of red blood cells.

Erythema

Redness of the skin caused by inflammation. In darker skin tones, erythema may appear as a purple tint.

Texture

The smoothness and dryness of the skin. Xerosis refers to excessive dryness, while seborrhea refers to excessive oiliness. Expected skin texture variations include blackheads, whiteheads, scarring, oily skin, and wrinkles.

Lesions

Abnormalities or changes in the skin's appearance. Types of lesions include vascular (bleeding under the skin), primary (flat or raised solid/fluid-filled), and secondary (changes to the surface, debris, alteration).

Malignant

Referring to a potentially cancerous lesion. The ANCDE rule can help identify potential malignancies based on asymmetry, border irregularity, color variation, diameter, and evolution.

Pressure Injury

Damage to the skin and underlying tissue caused by prolonged pressure, typically over a bony area. Pressure injuries are classified based on the depth and severity of the tissue damage.

Staging

The classification system used to categorize pressure injuries based on their severity. Stages range from

Tools used for a skin assessment

gloves, penlight, ruler

Ask the patient if they have a history of

rashes, allergies and treatments

What color is the nail plate

light pink

Angle between nail fold and nail plate should be

less than 180

Striae

stretch marks

Keloid

overgrowth of scar tissue

Velvety skin is a sign for

thyroid disease

Dry or flaky skin can be a sign for

dehydration, trauma, thyroid disease

Diaphoresis

Heavy sweating

Macule

flat rash

Patch

Birthmark

Papule

raised

Plaque

psoriasis, eczema

Nodular

melanoma

Tumor

Large and firm

Vesicle

fluid filled

Pustule

pus filled

Cyst

large filled with liquid

Ulcer

pressure injury

Excoriation

abrasions, scratching

Lichenification

thick raised skin caused by scratching

Types of patterns

linear, clustered, bulls eye, annular

Stage 1

Intact skin, non blanchable erythema

Stage 2

partial skin loss, shiny or dry

Stage 3

Full thickness skin loss, damage to the subcutaneous tissue

Stage 4

 exposed muscle, tendons, bone, necrotic tissue

Koilonychia

spoon shaped nails

Paronychia

inflammed

Tenting

remains in elevated position due to dehydration

Edema

excess fluid in intersitial space

pitting

leaving an indent

Lanugo

fine hair

Vernix Caseosa

Cheesy substance

Sebum

holding water in the skin producing milia

Chloasma

Discoloration in the face

Senile purpura

discoloration due to capillary fragility