Skin

PHYSICAL ASSESSMENT

Objectives  At

the end of the discussion the participants will be able to:  explain

the process of describing and classifying skin lesions  identify common skin lesions and discuss possible etiologies  describe methods used to assess the integumentary changes in both light and dark – skinned patients  perform physical assessment of the skin

THE INTEGUMENT  Includes

the skin, hair and nails

THE INTEGUMENT  Epidermis  Outermost

portion composed of stratum corneum plus cellular stratum  Protective layer, water proofing layer  Provides pigment or color to skin  Forms nails and hair

THE INTEGUMENT  Dermis  Vascular

connective layer that separates epidermis from adipose tissue  Sensory nerves and autonomic motor nerves are found here  Sweat glands and hair follicles originate in dermis

THE INTEGUMENT  Hypodermis  Dermis

connected to underlying organs by the hypodermis, a loosely connected tissue filled with fatty cells  Adipose tissue generates heat, provides insulation, shock absorption and a reserve of calories

THE INTEGUMENT  Glands

Found in Skin

 Eccrine

Sweat Glands - sweat glands to regulate body temperature.  Aprocine Glands - secrete odorless fluid in response to emotional or sexual stimuli. Found in the axillae, nipples, anogenital area, eyelids, and ears. Bacterial growth causes odor.  Sebaceous Glands - secrete sebum to keep skin and hair lubricated. Secretion varies in response to sex hormones (primarily testosterone).

Role of the Skin  Protection

from microbial invasion and minor trauma

 Retards

body fluid loss

 Regulates  Provides

body temperature

sensory perception

Role of the Skin  Produces

vitamin D from precursors

 Contributes  Repairs

to blood pressure regulation

surface wounds - scar formation

 Excretes

sweat, urea and lactic acid

 Expresses

emotions

Assessing the Skin  Equipment:

millimeter ruler clean gloves magnifying glass

Assessing the Skin  Implementation:

1. Introduce self, verify client’s identity and explain what you are going to do. 2. Perform hand hygiene and observe appropriate infection control procedures 3. Provide client privacy.

Assessing the Skin 4. Inquire if the client has any history of the following:  

    

pain or itching Presence and spread of lesions, bruises, abrasions, pigmented spots Previous experience with skin problems Family history Use of medications, lotions, home remedies Tendency to bruise easily Recent contact with allergens

Assessing the Skin 5. Inspect skin color:  Pallor  Cyanosis  Jaundice  Erythema  Vitiligo  Carotenemia  Albinism

Assessing the Skin 6. Inspect uniformity of skin color  Generally

uniform  Areas of lighter pigmentation (palms,lips, nail beds) in dark skinned people

7. Assess edema  Location,

color, temperature, shape, degree to which the skin is indented or pitted

Assessing the Skin Scale for describing edema 1+ = 2mm 2+ = 4mm 3+ = 6mm 4+ = 8mm

Assessing the Skin 8. Inspect, palpate and describe skin lesions  Describing skin • • • • •

lesions

Type or structure Size, shape and texture Color Distribution Configuration

Assessing the Skin  2.

Primary Lesions Macule – flat unelevated change in color, 1mm to 1cm e.g. freckles measles, flat moles

Assessing the Skin 2. Patch- flat unelevated, larger than 1 cm and may have irregular shape (e.g. vitiligo, birth mark)

Dark red patch with distinct borders extending from R ear across lower cheek and chin. Has been present since birth.

Depigmented patches of skin with distinct borders on ventral surface of R hand

Assessing the Skin 3. Papule – circumscribed, solid elevation of the skin, less than 1cm ( e.g. warts, acne) Three hard dry verrucous (warty) papules on middle finger of R hand. Warts

Assessing the Skin 4. Plaque – larger than 1cm ( e.g. psoriasis) Erythematou s plaque with silver-white scale on extensor surface of legs.

Assessing the Skin 5. Nodule – elevated solid hard mass that extends deeper into the dermis, 0.5 to 2cm

Three discrete hairless hyperpigment ed nodules measuring 4x2cm, 4x1.5cm, & 3x1cm

Assessing the Skin 6. Tumor – larger than 2cm and may have an irregular border 7. Vesicle, Bulla – a circumscribed, round or oval, thin translucent mass filled with serous fluid or blood (e. g. chicken pox) vesicles- are less than 0.5cm bullae- are larger than 0.5cm

Assessing the Skin Linear vesicles on ventral surface of forearm. Client reports lesions are intensely itchy.

Poison Ivy

Grouped vesicles on an erythematous base located below R eye.

Herpes Simplex Virus (Herpes Keratitis)

Assessing the Skin 8. Pustule – vesicle or bulla filled with pus.

Scattered papules and pustules on erythematous bases of varying diameters. Lesions noted to change location within hours.

Assessing the Skin 9. Wheal- a reddened localized collection of edema fluid, irregular in shape, size varies (e.g. hives, mosquito bites)

Assessing the Skin  Secondary

skin lesions

 Atrophy  Erosion  Lichenification  Scales  Crust  Ulcer  Fissure  Scar  Keloid  Excoriation

Assessing the Skin Acanthosis Nigricans

Dry thickened hyperpigmented skin with linear fissures across posterior neck

Licenification

Symmetrical pattern of lesions on flexor surfaces of knees and elbows. Client reports intense itching.

Assessing the Skin 9. Observe and palpate skin moisture.  Skin

folds and axillae  Hyperthermia and dehydration

10. Palpate skin temperature.  Compare

the two feet and two hands  Use back of the fingers

Assessing the Skin 11. Note skin turgor by lifting and pinching the skin on an extremity Asses for hydration by checking skin turgor over the sternum or clavicle

Assessing the Skin 12. Document findings in the client record using forms or checklist supplemented with narrative notes when appropriate.

Assessing the Skin Life Span Considerations: II. Infants     

Physiologic jaundice Milia Vernix caseosa Lanugo Mongolian spots

Assess skin turgor by pinching the skin on the abdomen

Assessing the Skin Milia

Mongolian spots

Assessing the Skin II. Children Normally have minor lesions  Secondary lesions may frequently occur  With puberty, oil glands become more productive 

III. Elders Skin losses elasticity, thin and translucent  Loss of dermis and subcutaneous fat  Dry and flaky  Senile lentigines or melanotic freckles  vitiligo 

Asses for hydration by checking skin turgor over the sternum or clavicle

References  Kozier

& Erb’s, (2008) Fundamentals of Nursing, 4th Edition, Volume II  Ellis, (2003) Basic Nursing Skills, 2nd Edition, Volume II  Daniel’s, (2007) Fundamental’s of Nursing, Volume I  Health Assessment, (2008), 8th Edition, p 341370  Delmar Learning – Audio Visual  www.imageask.com