COLLEGE OF MEDICINE AND HEALTH

SCIENCE DEPARTMENT OF ADULT

HEALTH NURSING
Advanced assessment of skin
 INTRODUCTION
Anatomic and Physiologic overview
• The largest organ system of the body is the skin ,it
is 16% of our body weight. It forms a barrier
between the internal organs and the external
environment and participates in many vital body
functions. The skin is contiguous with the mucous
membrane at the external openings of the
digestive, respiratory, and urogenital systems.
 Its functions include
• Protection: barrier against the outside

• Protection against dehydration

• Body temperature regulation

• Cutaneous sensation

• Metabolic functions

• Blood reservoir

• Excretion
Anatomy
• Epidermis
– Stratum germinativum (basal cell layer)
• Mitosis occurs here
• Contains melanocytes,
producing melanin
– Stratum corneum
• As cells rise, they die and their
cytoplasm is converted to
keratin, which has a rough,
horny texture
• This layer undergoes constant
shedding
• Dermis
– Mostly connective tissue, primarily
collagen
– Provides support and nourishment of
epidermis
– Blood vessels, nerves, muscle, sweat
glands, sebaceous glands, hair follicles
• Subcutaneous Layer (Hypodermis)
– Consists mostly of fat
– Provides protection, insulation, and
caloric source
 History
 History of skin disease
 What was it? How was it treated?
 Does it run in the family?
 Significant familial predispositions – allergies, hay
fever, psoriasis, eczema, acne
 Any know allergies?
 Any tattoos or birthmarks?
 Use of non sterile equipment for tattoos increases
risk of Hep C
 Change in pigmentation
 Might suggest systemic illness (jaundice)
 Change in a mole
 Pruritus
 Any dryness? Is it seasonal?
 Xerosis – dry
 Seborrhea - oily
 History
• Excessive bruising
– Consider abuse
– Frequent minor trauma may be sign of alcohol
abuse
• Rash or lesion
– Onset
– Location
– Spread
– Character or quality
– Duration
– Associative factors – pets, co-worker?
– Alleviating and aggravating factors – what have
you tried to do?
– Patient’s perception - what do you think it is?
• Medications
– Prescription and over-the-counter
• May indicate allergy to medication
 History
 Hair loss or growth
 Gradual or sudden?
 Hirsutism – unusual growth
 Change in nails
 Exposure to hazards
 May be environmental or occupational
 Bitten by bee, tick, mosquito?
 Exposure to plants or animals?Self care

 What cosmetics, soaps, chemicals?

Possible allergies
 Physical Examination - Color
• General pigmentation – • Vitiligo – absence of
should be even melanin in patchy areas
throughout
• Benign pigmented areas
– Freckles (macules) on *****
ABCDE of malignant melanoma
sun exposed skin
– Nevi (moles) 1. Asymmetry – one lesion that is
• Junctional nevi – not regularly round or oval
macular only 2. Border – irregular
3. Color – variations
• Compound nevi – 4. Diameter – greater than 6mm
macular and 5. Elevation
papular
• Dysplastic -
precancerous
– Birthmarks
 Physical Assessment
• Equipment
Penlight Tongue depressor Centimeter
rule Gloves
Magnifying glass Flashlight Wood’s lamp

9
 Technique to examination of skin
• Inspection Palpation
Inspections and palpation of skin
Color Moisture Temperature
Thickness
Turgor Vascular changes Edema
Lesions
Skin odors are usually noted in the skin fold.
 Changes in Color in Light Skinned People
 Pallor
 Pale, white color caused by decrease of blood flow
(vasoconstriction) or decrease in hemoglobin
 Shock, anemia
 Erythema
 Redness due to increased blood flow
(vasodilation)
 Fever, inflammatory process, emotions, CO
poisoning
 Cyanosis
 Bluish, purplish hue due to decreased perfusion of
tissues
 Hypoxemia due to heart failure, shock, chronic
bronchitis
 Cont..
 Jaundice
 Yellow, orange hue due to jaundice (increased
bilirubin in blood)
 Due to liver problems such as hepatitis,
cirrhosis
 Hyperpigmentation
 Hypopigmentation – vitiligo
 Petechiae , Ecchymosis, Purpura
13
 Color Changes in Darker Skinned People
 Pallor
 Brown skinned people will be more yellow. Black
skinned people will be more gray
 Palpebral conjunctiva and nail beds should be
observed
 Erythema
 Cannot be observed
 If fever suspected, check skin for warmth. If edema,
check skin for tightness
 Cyanosis
 Darker skinned people have normal bluish tone on
lips
 Palms, but not clearly evident, other clinical signs
should be observed
 Cont..
 Jaundice
 Hard and soft palate must be observed in addition to
sclera of eyes
 Dark urine also present
Acanthuses nigricans
Roughening and darkening of skin in localized areas,
especially the posterior neck(AN), a linear streak like
pattern in dark-skinned people, suggests diabetes
mellitus
 Assessment of the skin
• Includes inspection & palpation
• Six observation in assessing the skin:
o Color
o Moisture
o Temperature
o Texture
o Mobility and turgor
o Presence of lesions
 Skin …
1. Color

 General pigmentation: normally it is consistent with

the genetic background and varies from light to dark
brown.

• Dark skinned people normally have areas of lighter

pigmentation on the palms, nail beds and lips.

• Vitiligo : the complete absence of melanin pigment on

the face, neck, hands and feet.
 Skin …
 Widespread color change

• Pallor: Pallor due to decreased redness is

seen in anemia and in decreased blood flow,

as in fainting or arterial insufficiency.
 Skin …
Cyanosis:

• Central cyanosis is best identified in the lips, oral

mucosa, and tongue.

• Causes of central cyanosis include advanced lung

disease, congenital heart disease, and abnormal
hemoglobin.

• Cyanosis of the nails, hands, and feet may be

central or peripheral in origin.
 Skin …
• Peripheral cyanosis may be caused by anxiety or a cold
examining room.

• Venous obstruction may cause peripheral cyanosis.

• Cyanosis in congestive heart failure is usually

peripheral, reflecting decreased blood flow, but in
pulmonary edema it may also be central.
Jaundice
 Skin …
2. Moisture
• Examples are dryness, sweeting, and oiliness.
sweeting in hypoglycemia, TB and other systemic illness
Dryness in hypothyroidism, dehydration, oiliness in acne
3. Temperature
Use the backs (dorsa) of your fingers to make this
assessment and check bilaterally
 Skin …
4. Texture

• Examples are roughness and smoothness.

• Normal skin feels smooth and firm with an even

surface and abnormality include roughness in
hypothyroidism.
 Skin …
5. Mobility and Turgor
• Lift a fold of skin and note the ease with which it lifts up (mobility)
and the speed with which it returns into place (turgor).

• Abnormalities are decreased mobility in edema and decreased

turgor in dehydration
 Skin …
6. Lesions
1.Their anatomic location and distribution : over the
body, are they generalized or localized?
• Acne affects the face, upper chest, and back;
• psoriasis, the knees and elbows (among other areas);
and
• Candida infections, the intertriginous areas (skin fold)
 Skin …
2. Their arrangement: For example, are they linear,
clustered, annular (in a ring), arci-form (in an arc), or
dermatomal (covering a skin band that corresponds to a
sensory nerve root).
• Vesicles in a unilateral dermatomal pattern are typical of
herpes zoster.
3.. The type(s) of skin lesions (e.g., macules, papules,
vesicles, nevi).
 Primary vs. Secondary
• Primary skin lesions
– Variations in color or texture that may be
present at birth, such as moles or
birthmarks, or that may be acquired
during a person's lifetime, such as those
associated with infectious diseases (e.g.
warts, acne, or psoriasis), allergic
reactions (e.g. hives or contact
dermatitis), or environmental agents
(e.g. sunburn, pressure, or temperature
extremes).
 Cont..

• Secondary skin lesions

– Changes in the skin that result from
primary skin lesions, either as a natural
progression or as a result of a person
manipulating (e.g. scratching or picking
at) a primary lesion.
 Primary Skin Lesions
• Macule
– color change and less
than 1 cm
– may be to darker or
lighter
– Freckles, flat nevi,
hypopigmentation,
petechiae
• Patch
– Color change and
greater than 1cm
– Mongolian spots,
vitiligo, chloasma
Primary Skin Lesions
• Papule
– Elevated lesion less
than 1cm in diameter
– Due to elevation in
epidermis
– Ex: wart, elevated
nevus
• Plaque
– Elevation greater
than
– 1cm in diameter
– Ex: psoriasis
Primary Skin Lesions
• Nodule
– Elevated solid
greater than 1cm
– Extending deeper
into dermis
• Tumor
– Greater than few
cm in diameter
– May be firm or soft
 Primary Skin Lesions
• Wheal
– Superficial,
raised,
transient, and
erythematous
lesion
– Ex. Mosquito
bite, allergic
reaction
Primary Skin Lesions
• Cyst
– Encapsulated fluid
filled cavity in dermis
or subcutaneous layer
• Vesicle
– Elevated cavity
containing free fluid,
clear
– Less than 1cm
diameter
– Ex: herpes simplex,
varicella zoster
 Primary Skin Lesions
• Bulla
– Larger than 1cm in
diameter
– Superficial in
epidermis, thin
walled
– Ex: blisters, burns
• Pustule
– Pus in cavity
– Ex: impetigo, acne
 Secondary Skin Lesions
• Crust
– Thick, dry exudate
after rupture or
drying up of vesicle or
pustule
– Ex: Impetigo, scab
following abrasion
• Scale
– Dry or greasy flakes
of skin resulting from
shedding of excess
keratin cells
– Ex: psoriasis, eczema,
seborrheic dermatitis
Secondary Skin Lesions
• Fissure
– Linear cracks
extending into dermis
• Ulcer
– Deep depression
extending into dermis
– May bleed. Leave
scar.
• Excoriation
– Self inflicted abrasion
often from scratching
Secondary Skin Lesions
• Lichenification
– Tightly packed
papules from
prolonged intense
scratching
• Keloid
– Hypertrophic scar
– Cannot be removed
surgically
– More common in
black people
 Skin Lesions associated with AIDS –
Kaposi’s Sarcoma
• Patch stage
– Early lesions are faint and
pink
• Advanced stage
– Widely disseminated lesions
involving skin, mucous
membranes, and visceral
organs
– Violet colored tumors on nose
and face
• Epidemic stage
– Lesions develop into raised
papules of thickened plaques.
– Oval in shape and vary in
color from red to brown.
 Palpate skin to assess texture

• Use the palmar • Normal Skin is

surface of your smooth and even.
three middle
fingers to
• palpate skin
texture. • Rough, flaky, dry
skin is seen in
hypothyroidism
 Palpate to Assess Thickness
• If lesions are noted  Skin is normally thin, but
calluses (rough, thick
when assessing skin sections of epidermis) are
thickness, put gloves common on
on and palpate the  areas of the body that are
lesion between the exposed to constant
pressure
thumb and finger.
• Observe for drainage
or other
characteristics. • Very thin skin may be
• Measure the lesion seen in clients with
with a centimeter arterial insufficiency or
in those on steroid
ruler. therapy.
 Skin Assessment - shapes
• Annular
– Circular, beginning in
center and spreading to
periphery (ringworm)
• Polycyclic
– Annular lesions that grow
together
• Confluent
– Lesions run together
(hives)
• Discrete
– Individual lesions that
remain separate
 Shapes
• Grouped
– Clusters of lesions
(contact dermatitis)
• Gyrate
– Twisted, coiled
• Target
– Concentric rings of color
• Linear
– Scratch like, stripe
• Zosteriform
– Follow nerve route
(shingles)
 The End

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