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Skin

The document discusses how to assess the skin through physical examination including describing common skin lesions, structures of the integumentary system, and methods for evaluating the skin, hair, and nails across the lifespan.

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malyn1218
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1K views34 pages

Skin

The document discusses how to assess the skin through physical examination including describing common skin lesions, structures of the integumentary system, and methods for evaluating the skin, hair, and nails across the lifespan.

Uploaded by

malyn1218
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

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
 Includesthe 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 body temperature
 Provides sensory perception
Role of the Skin
 Produces vitamin D from precursors
 Contributes to blood pressure regulation
 Repairs 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
 Primary Lesions
2. 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


Depigmented patches
borders extending from R ear
of skin with distinct
across lower cheek and chin.
borders on ventral surface of
Has been present since birth.
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
Grouped vesicles
on ventral surface of forearm.
on an erythematous
Client reports lesions
base located below R
are intensely itchy.
eye.

Herpes Simplex Virus (Herpes


Poison Ivy 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 Licenification
Nigricans

Dry thickened hyperpigmented skin Symmetrical pattern of


with linear fissures across posterior lesions on flexor surfaces of
neck knees and elbows. Client
reports intense itching.
Assessing the Skin
9. Observe and palpate skin moisture.
 Skinfolds 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 341-
370
 Delmar Learning – Audio Visual
 [Link]

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