SKIN

 Inspect for uniformity of skin color.

 ________________– decreased redness like in
anemia
 ________________bluish discoloration
 a.__________________– bluish tinge like in
COPD, congenital heart disease
 b._________________– venous obstruction
 ________________– yellow color found in
sclera, _______________conjunctiva, skin etc.
 ____________________– yellow color d/t diet
rich in ____________. Found in
_________________
 ________________– roughening and
darkening of the skin in localized areas
 _______________– generalized loss of
pigmentation
 ________________– skin redness and warmth
(inflammation, allergic reactions and trauma)
 2. Assess edema if present
 Let patient sit _____________
 Palpate the ________________by pressing the
skin between _________________for
___________
 Run finger pads over area pressed and note
indentation
 If (+)_________________and note point at
which swelling is not present anymore
 Scale of edema:
 1+ barely detectable (__________)
 2+____________ (2-4mm)
 3+ ____________
 4+ ____________
 3. Inspect, palpate and describe skin lesions.
Use gloves as needed.
 A. Flat, nonpalpable lesion with skin color
changes
 Macule,
 patch
 Plaque, papule, nodule, cyst, wheal
 Palpable elevations: _________________
 Vesicle, bulla, pustule _________________
 Pregnant women may _____________,____________________
(stretch marks)
 TYPES OF SKIN LESION:(secondary )
 4. Observe and palpate skin moisture
 Dryness)
 Oiliness Sweating or if too much sweating (__________________)
due to hyperthermia or ________________
 *Skin integrity esp. pressure point areas (sacrum, hips, elbows)
 N: intact, no redness
 AbN: (+) skin breakdown, redness, warmer than other body parts
w/c may lead to pressure ulcers
 Skin texture and thickness
 Rough, flaky, dry skin _______________
 Obese clients report dry, itchy skin
 Thickness:
 N: thin w/o _____________(rough, thick
sections of epidermis commonly seen in
parts exposed to constant pressure)
 AbN: very thin skin (arterial insufficiency or
steroid therapy)
 5. Skin temp.
 Compare feet and both hands using back of
fingers
 Finding : uniform within normal range
 AbN: generalized hyperthermia__________
 generalized hypothermia_____________
 localized
hyperthermia_________________
 localized hypothermia
_________________


 6.Skin turgor cephalocaudal)

 ____________________– refers to how easily
the_________________.
 How to check?
 lift fold of skin and note ease with which it
lifts up
 ________________ – refers to skin’s
______________and _______________the skin
returns to its original shape
after____________________.
 How?
 Adult/child : forehead, chest, abdomen,
extremities
 Elderly _______________________only
 N: skin pinches easily and immediately returns to
original position.
 Older pts: decrease elasticity and collagen fibers,
sagging or wrinkled skin in the face, breasts and
scrotal areas
 AbN: decrease mobility
 decrease turgor
 7. document
 Draw location , size and describe skin lesions
on the body surface diagram
 Lifespan considerations
 INFANTS
 ___________________may appear in newborns 2 to 3
days after birth and usually lasts about______________.
_________________jaundice, or that which indicates a
disease, ________________________and may lasts more
than 8 days
 Newborns may have
_____________(whiteheads), small nodules over
the nose and face,and
___________________(white cheesy, greasy
material on the skin)
 Lifespan considerations
 Premature infants may have________________, a fine
downy hair covering their shoulders and back
 In dark- skinned infants, areas of
hyperpigmentation may be found on the back,
especially in the sacral area.
 _____________dermatitis may be seen in infants
 If a rash is present, inquire in detail about
immunization history
 Assess skin turgor by pinching the
____________________
 Lifespan considerations
 CHILDREN
 Children normally have minor skin lesions) on arms
and legs due to ____________________level. Lesions
on other parts of the body may be signs
of_________________________ and a thorough
history should be taken
 _____________skin lesions may occur
frequently as children
______________________________
 Lifespan considerations
 With puberty, oil glands become more productive,
and children may ________________Most persons
_________________have some acne.
 In dark-skinned children, areas of
______________________may be found on the back
especially in the_____________________.
 If rash is present, inquire in detail about
immunization history
 Lifespan considerations
 ELDERS
 Changes in white skin occur at an earlier age than in
black skin
 The skin loses its__________________. Wrinkles first
appear on_____________________and neck, which
are abundant__________________________.
 The skin _________________________because of loss
of dermis and subcutaneous fat.
 Lifespan considerations
  The skin is _______________because sebaceous and
sweat glands_____________. Dry skin is more
prominent____________________.
 The skin takes longer return to its natural shape after
being tented between the
____________________________
 Due to the loss of peripheral skin turgor in
elders, assess for______________ by checking
skin turgor over
the___________________________.
 Lifespan considerations
 Flat tan to brown-colored___________, referred
to as senile ________________________freckels,
are normally apparent on the back of the hand
and other skin areas that are exposed to the
sun. these macules may be as large
_______________________