SKIN

Overview of Skin Assessment

  • Skin assessment can be integrated with a full physical exam or performed as a standalone visit.

  • Understand the client's reason for visit and expectations.

  • Techniques:

    • Inspection: check for color, texture, moisture, integrity.

    • Palpation: assess for texture, moisture, temperature, mobility, turgor.

Client Engagement

  • Maintain an ongoing commentary during the assessment to explain actions and findings.

  • Encourage client participation (e.g., raising arms, removing socks).

  • Allow for questions or pauses during the assessment.

Post-Assessment Instruction

  • Provide personalized health promotion instructions.

  • Educate on self-care activities, prevention, and monitoring skin and nail conditions.

  • Complete documentation, capturing clinical impressions for future comparison.

Necessary Tools for Skin Assessment

  • Pen Light: For close examination and good lighting.

  • Gloves: Worn if moisture, weeping, or bleeding is present to maintain infection control.

  • Ruler: A centimeter ruler to measure unexpected findings.

Anatomy of the Skin

  • Skin is the largest organ, consisting of three layers:

    • Epidermis: Outermost layer; consists of keratin and melanocytes.

    • Dermis: Middle layer; made of collagen, blood vessels, nerves, hair follicles.

    • Subcutaneous Layer: Bottom layer; consists of adipose tissue for temperature regulation and cushioning.

Physiology of Skin and Nails

  • Functions:

    • Protection of internal organs.

    • Regulation of body temperature through sweating and shivering.

    • Sensory perception (temperature, touch, pain).

    • Waste excretion.

    • Vitamin D production from skin exposure to sunlight, food, and supplements.

Client Interview for Skin/Nail Health

  • Collect subjective data through questions:

    • History of allergies, rashes, skin problems, and their timeline.

    • Noticeable changes in skin/nails and treatments sought.

    • Current issues like itching, bruising, lumps, etc.

    • Personal skincare routines and family history of skin cancer.

Expected Findings in Skin Assessment

  • Skin color should be even and consistent with genetic background.

  • Variations in pigmentation can indicate health issues:

    • Cyanois: Bluish skin, result from high levels of deoxygenated hemoglobin in blood; check oral mucosa in dark skin clients.

    • Erythema: Redness due to inflammation.

    • Jaundice: Yellowish skin from increased bilirubin; liver dysfunction or bile duct obstruction.

    • Pallor: Paler skin indicating anemia.

    • Petechiae: reddish/purple spots, caused by bleeding under skin

    • Xerosis: Dry skin resulting from a lack of moisture, often leading to scaling or itching.

    • Seborrhea: excessive oiliness of the skin, often resulting in flaky scales or crusty patches.

    • Urticaria: hives or welts on the skin, often caused by an allergic reaction, characterized by raised, itchy areas.

Unexpected Findings

  • Hyperpigmentation: Increased melanin leads to dark spots (e.g., freckles, age spots).

  • Hypopigmentation: Decreased melanin, observed in conditions like vitiligo.

  • Skin lesions: Note color, height, shape, drainage, size, and location.

  • Assess edema presence and characteristics (pitting vs non-pitting).

Types of Skin Lesions

  • Vascular Lesions: Result from blood vessel issues (e.g., petechiae, ecchymosis).

  • Primary Lesions: Initial changes (e.g., macule, papule, plaque).

  • Secondary Lesions: Evolve from primary lesions (e.g., crust, scale).

  • Potentially Malignant Lesions: Signs indicative of skin cancer (e.g., the ABCDE assessment for melanoma).

  • Wheals: Raised, itchy areas often seen in hives, caused by an allergic reaction or localized edema.

  • Fissures: Linear breaks in the skin, often associated with dryness, common in areas like the corners of the mouth or between the toes.

  • Crusts: Dried exudate on the skin, usually a result of ruptured vesicles or pustules.

  • Macules: Flat, discolored areas of the skin that are usually smaller than 1 cm, representing localized changes in skin color.

  • Papules: Small, raised, solid pimples, often less than 1 cm in diameter.

  • Plaques: Elevated, flat lesions larger than 1 cm, often formed from confluence of papules.

  • Vesicles: Fluid-filled sacs on the skin, typically smaller than 1 cm, often associated with conditions like herpes or chickenpox.

  • Pustules: Vesicles filled with pus, commonly associated with acne or other infections.

  • Primary Lesions: Initial skin changes from a disease process.

  • Secondary Lesions: Changes that evolve from primary lesions due to scratching, infection, or other external factors.

  • Potentially Malignant Lesions: Signs indicative of skin cancer (e.g., the ABCDE assessment for melanoma).

Four Stages of Skin Lesions

Stage I

A Stage I pressure injury manifests as nonblanchable redness, particularly over a bony prominence, with the skin remaining intact.

Stage II

A Stage II pressure injury may appear as a shallow ulcer with a dry or shiny pink wound bed, or it could be presented as an area with blisters.

Stage III

A Stage III pressure injury penetrates completely through the epidermis and extends into the subcutaneous tissue, where subcutaneous fat may become visible.

Stage IV

A Stage IV pressure injury extends through all layers of the skin, revealing underlying muscle, bones, or tendons.

Health Promotion Strategies

  • Educate on bathing and hygiene tailored to individual skin needs.

  • Sun protection: Apply broad-spectrum sunscreen (SPF 30+), wear protective clothing, avoid tanning beds.

  • Regular self-assessment of skin for changes in moles, identifying concerning signs.

  • Document findings and follow up on any suspicious changes with healthcare providers.

Definitions of Skin Conditions

  • Cyanosis: A abnormal purplish or bluish discoloration of the skin or mucous membranes, usually occurring in the fingers, lips and toes, due to high levels of deoxygenated hemoglobin in the blood.

  • Ecchymosis: Extravasation of blood into the skin or mucous membranes resulting in a nonelevated, rounded or irregular patch. In people who have light skin, it assumes a purplish-blue tone while in people who have darker skin, it appears more ashen-gray. It is larger than a petechiae.

  • Edema: Excessive fluid accumulation within the interstitial or intracellular spaces.

  • Erythema: Redness of the skin caused by dilation of the superficial capillaries.

  • Jaundice: Yellowish discoloration of the skin, mucous membranes and sclerae due to abnormal excess of bilirubin in the blood.

  • Pallor: Paleness; a decrease or absence of skin coloration.

  • Petechiae: Reddish or purplish pinpoint-sized spots of discoloration on the skin or mucous membranes, due to hemorrhages.

  • Vitiligo: Disorder where nonpigmented white patches of varied sizes appear on otherwise normal skin because of the loss of pigment-producing skin cells in the epidermis.