ASSESSMENT

OF THE SKIN

MARY JANE MAPA, RN MAN

 FUNCTIONS OF
THE SKIN
• Largest organ of the body
• Physical barrier that protects the
underlying tissues and organs from
microorganisms, physical trauma,
ultraviolet radiation, and dehydration.
• It plays a vital role in:
• Maintenance of temperature
• Fluid and electrolyte imbalance
• Absorption
• Excretion
• Immunity and vitamin D synthesis
 COLLECTION OF
SUBJECTIVE DATA
QUESTION
Are you experiencing any
current skin problems such
as rashes, lesions, dryness,
oiliness, drainage, bruising,
swelling, or changes in skin
color? What triggers it?
RATIONALE
-maybe caused by pathologic
condition
- Bruising, welts, swelling
maybe a sign of physical
abuse
- Dry itchy skin is common
in obese patient
 COLLECTION OF
SUBJECTIVE DATA
QUESTION
Do you have any birthmarks
or moles? If so, please
describe them. Have any of
them changed color, size, or
shape?
RATIONALE
A change in the appearance
or bleeding of any skin mark,
especially a mole, may
indicate cancer.
 COLLECTION OF
SUBJECTIVE DATA
QUESTION
Have you noticed any change
in your ability to feel pain,
pressure, light touch, or
temperature variations?
RATIONALE
Changes in sensation or
temperature may indicate
vascular or neurologic
problems such as peripheral
neuropathy related to
diabetes mellitus or arterial
occlusive disease
 COLLECTION OF
SUBJECTIVE DATA
QUESTIONS RATIONALE
Are you experiencing any -Pruritus may be seen with dry
pain, itching, tingling, or skin, drug reactions, allergies,
lice, insect bites, uremia, or
numbness?
obstructive jaundice.
-Abnormal sensations of
tingling, pricking, or burning are
referred to as paresthesia.
-Numbness or dulling of the
sensa- tions of pain,
temperature, and touch to the feet
may be seen in diabetic
peripheral neuropathy.
 COLLECTION OF
SUBJECTIVE DATA
QUESTION
Are you taking any medications
(prescribed or “over the coun-
ter”), using any ointments or
creams, herbal or nutritional
supplements, or vitamins? How
long have you been taking each
of these?
RATIONALE
-Some medications can cause
photosensitivity reactions after
being exposed to the sun.
-Some clients may exhibit
allergic skin reaction to specific
drugs.
PROCEDURE
EQUIPMENT
 CENTIMETER RULER

•GLOVES

MAGNIFYING
GLASS

PEN LIGHT
 • Introduce yourself and
verify the client’s
identity. Explain to the
client what are you
STEP 1 going to do, why it is
necessary, and how the
client can cooperate.
 • Perform hand hygiene,
and observe other
STEP 2 appropriate infection
control procedures.
 • Provide for client’s
STEP 3 privacy
 • Note for any
distinctive odor
• NORMAL
FINDINGS:
STEP 4 Client has slight or no
odor of perspiration,
depending on activity.
 ABNORMAL FINDINGS

• Strong odor of perspiration or foul odor may

indicate disorder of sweat glands.
• Poor hygiene practices may indicate a need
for client teaching or assistance with
activities of daily living.
 • Inspect for skin
coloration
• NORMAL
FINDINGS:
Evenly colored skin
STEP 5 tones without unusual
or prominent
discolorations.
 ABNORMAL FINDINGS
PALLOR
• loss of color in skin due to the absence of oxygenated
hemoglobin caused by vasoconstriction, cold
environment, decrease tissue perfusion due to
shock, hypotension, lack of oxygen and anemia.
• Can be seen in the face, mouth, conjunctivae, and
nails
 ABNORMAL
FINDINGS
CYANOSIS
• Mottled blue color in skin
and its appendages due to
inadequate tissue
perfusion with oxygenated
blood.
• Can mostly be seen in the
lips, oral mucosa, and
This Photo by Unknown Author
is licensed under CC BY-SA
tongue, nail beds
 ABNORMAL
FINDINGS
JAUNDICE
• Is characterized by
yellow skin tones,
from pale to
pumpkin,
particularly in the
sclera, oral mucosa,
palms, and soles.
 ABNORMAL
FINDINGS
ACANTHOSIS
NIGRICANS
Is roughening and
darkening of skin in local-
ized areas, especially the
posterior neck
 • Inspect for color variation in localize part of
the body
• Normal findings: Common variations include

STEP 6
suntanned areas, freckles, or white patches
known as vitiligo.
• Albinism- generalize loss of pigmentation.
VITILIGO
ALBINISM

This Photo by Unknown Author is licensed under CC BY-SA-NC

 ABNORMAL FINDINGS

• Rashes
• Malar rash (Butterfly rash)- seen in the face
of SLE patients
• Freckles
BUTTERFLY RASH

FRECKLES
 • Inspect and palpate for
primary, secondary,
vascular lesions. Note for
size, shape, distribution ,
and configuration. Apply
gloves if lesion is open or
STEP 7 draining.
• NORMAL FINDINGS:
Skin is smooth without
lesions
 PRIMARY
LESIONS:
MACULE AND
PATCH
•Small, flat,
nonpalpable skin color
change (brown, white,
tan, purple, red)
•Macules are less than
1cm with a
circumscribed border
•Patches are greater
than 1cm and may have
an irregular border
 PLAQ
PRIMARY SKIN
PAPULE
UE

LESIONS
PRIMARY SKIN LESIONS:
NODULES AND TUMORS
• Elevated, solid,
palpable mass that
extends deeper into
dermis than a papule
• Nodules are 0.5 – 2 cm
and circumscribed
• Tumors are greater
than 1 – 2cm
 PRIMARY SKIN LESIONS:
VESICLE AND BULLAE
• Circumscribed elevated,
palpable mass containing serous
fluid
• Vesicles are less than 0.5 cm
(herpes simplex/zoster,
varicella)
• Bullas are greater than 0.5 cm
(large burn blisters
 PRIMARY SKIN LESION:
WHEAL
• Elevated mass with transient
borders that is often irregular
• Size and color vary
• Examples include urticaria
(hives) and insect bites
 PRIMARY SKIN LESION:
PUSTULE
• Pus-filled vesicle or
bulla
• Examples include acne
 PRIMARY SKIN LESION:
CYST
• Encapsulated fluid-filled
or semisolid mass that is
located in the
subcutaneous tissue or
dermis
 SECONDARY SKIN LESIONS

• EROSION
• Loss of superficial epidermis that does not extend to
the dermis. It is depressed, moist area.
• ULCER
• Skin loss extending past epidermis, with necrotic
tissue loss. Bleeding and scarring are possible.
• FISSURE
• Linear crack in the skin that may extend to the
dermis and may be painful.
• SCAR
• Skin mark left after healing of wound or lesion that
represents replacement by connective tissue of the
injured tissue.
SECONDA
RY SKIN
LESIONS
FISSURES

ULCERS
EROSION
 VASCULAR SKIN LESIONS

Petechiae (Pl. Ecchymosis (Pl.

petechiae)
Round red or purple macule that is 1-2 mm in
size. It is secondary to blood extravasation
Ecchymoses)
Round or irregular macular lesion that is larger
than petechial lesion. Color varies and changes:
and associated to with bleeding tendencies or
black, yellow, and green hues.
emboli to skin
 VASCULAR LESIONS

Hematom
a collection of blood
A localized
creating an elevated ecchymosis. It
is associated with trauma.
Cherry
Papular Angioma
and round, red or purple
lesion found on the trunk or
extremities. It may blanch with
pressure.
 VASCULAR LESIONS
Spider
Angioma
Red arteriole lesion with a central body
with radiating branches. Usually noted on
the face, neck, arms, and trunk. Associated
with liver disease, pregnancy, vitamin B
deficiency
Telangiectasis (Venous
Star)
Bluish or red lesion with varying
shape found on the legs and
anterior chest. Does not blanch
when pressure is applied.
 • Palpate texture if it is rough or
smooth using palmar surface
of three middle finger.
• Normal Findings:
• Skin is smooth and even
• Palpate for thickness

STEP 8 • Normal Findings:

• Skin is normally thin but
calluses (rough, thick sections
of epidermis) are common on
areas of the body that are
exposed to constant pressure.
 ABNORMAL FINDINGS
• Rough, flaky, dry skin is seen in hypothyroid- ism.
Obese clients often report dry, itchy skin
• Very thin skin may be seen in clients with arterial
insufficiency or in those on steroid therapy.
• Infected lesions may be tender to palpate.
Nonmobile, fixed lesions may be cancer.
 • Palpate temperature (warm,
hot, cold) and moisture (dry,
sweaty, oily) using dorsal part
of the hand.
• Normal Findings

STEP 9 • Skin is warm equally on both

upper and lower extremities.
• Moisture of the skin depends on
the area being assessed. Recent
activity makes the skin sweaty
and moist.
 ABNORMAL FINDINGS
• Cold skin may accompany shock or hypotension. Cool skin may accompany
arterial disease. Very warm skin may indicate a febrile state or
hyperthyroidism.
• Increased moisture or diaphoresis (profuse sweating) may occur in
conditions such as fever or hyperthyroidism. Decreased moisture occurs with
dehydration or hypothyroidism.
 • Palpate mobility and skin
turgor by lightly pinching up
the skin over sternum.

STEP • Normal Findings:

• The skin is mobile, with
10 elasticity and returns to
original shape quickly.
 ABNORMAL FINDINGS
• Decreased mobility is seen with edema. Decreased
turgor (a slow return of the skin to its normal state
taking longer than
30 seconds) is seen in dehydration.
• The older client’s skin loses its turgor because of a
decrease in elasticity and collagen fibers. Sagging or
wrinkled skin appears in the facial, breast, and
scrotal areas.
 • Palpate for edema for by
pressing thumb over feet or
ankle.

STEP • Normal findings:

• Skin rebounds and does not
11 remain indented when
pressure is released.
 ABNORMAL FINDINGS
• Indentations on the skin
may vary from slight to
great and may be in one area
or all over the body.
SWELLING VS EDEMA
EDEMA SCALING
ASSESSMENT OF
THE HAIR
 • Inspect the scalp and hair for
general color and condition by
separating the hair at 1 inch
interval, inspect and palpate
the hair and scalp for
cleanliness, dryness or
oiliness, parasites, and lesions.

STEP 1 • Normal findings

Scalp is clean and dry. Sparse
dandruff may be visible. Hair is
smooth and firm
No lesions nor any infestations
noted.
 ABNORMAL FINDINGS

• Nutritional deficiency: patchy gray hair, red copper hair color in severe
malnutrition.
• Excessive scaliness may indicate dermatitis.
• Raised lesions may indicate infections or tumor growth.
• Dull, dry hair may be seen with hypothyroidism and malnutrition.
• Pustules with hair loss in patches are seen in tinea capitis,
• Infections of the hair follicle (folliculitis) appear as pustules surrounded
by erythema
•
Tinea Capitis (scalp) Foliculitis (scalp)

Patchy hair loss

 • Inspect amount and
distribution of scalp, body,
axillae, and pubic hair. Look
for unusual growth elsewhere
on the body.
• Normal findings
STEP 2 Hair is evenly distributed in parts
of the body. There is no unusual
growth nor hair loss is noted as
verbalized by the client
 ABNORMAL FINDINGS
• Excessive generalized hair loss may occur with infection,
nutritional deficiencies, hormonal disorders, thyroid or
liver dis- ease, drug toxicity, hepatic or renal failure. It
may also result from chemotherapy or radiation therapy.
• Patchy hair loss may result from infections of the scalp,
discoid or systemic lupus erythematosus, and some types
of chemotherapy.
• Hirsutism (facial hair on females) is a char- acteristic of
Cushing’s disease and results from an imbalance of
adrenal hormones or it may be a side effect of steroids
 HIRSUTUISM

ALOPECIA AREATA
ASSESSMENT OF THE
NAILS
 NAILS
• Hard, transparent plates of
keratinized epidermal cells that grow
from the cuticle.
• Nail body extends over the entire
nail bed and has a pink tinge as a
result of blood vessels underneath.
• Lunula is a cresent-shaped area
located at the base of the nail.
 • Inspect for grooming and
cleanliness
• Normal findings
Nails are clean and trimmed. No
hang nails noted.

STEP 1 • Abnormal findings: Dirty,

broken, or jagged fingernails
may be seen with poor hygiene.
They may also result from the
client’s hobby or occupation.
 • Inspect for nail color and markings
• Normal findings
• Pink tones is seen. Longitudinal ridging is
STEP 2
seen
• Dark-skinned clients may have freckles or
pigmented streaks in their nails.
 ABNORMAL FINDINGS
• Pale or cyanotic nails may indicate hypoxia or
anemia.
• Splinter hemorrhages may be caused by trauma.
• Yellow discoloration may be seen in fungal
infections or psoriasis
Yellow Nail Syndrome

Koilonychia

Paronchia Pitting
 • Inspect shape of the nails

STEP 3
 • Palpate for texture and
consistency
• Normal findings
Nails are hard and immobile
STEP 4 Nails are smooth and firm; nail
plate should be firmly attached
to nail bed.
ABNORMAL
Onichomycosis Onicholysis

FINDINGS
 • Test for capillary refill by
pressing the nail tip briefly and
watching for color change
• Normal findings

STEP5
• Pink tone returns immediately
to blanched nail beds when
pressure is released.
CAPILLARY REFILL