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Skin Assessment

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Skin Assessment Peggy Korman, CNM NRS 320 Foundations of Nursing Practice Integumentary System Nails Hair skin Assessment Techniques Inspection Palpation Olafactory ... – PowerPoint PPT presentation

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Title: Skin Assessment


1
Skin Assessment
  • Peggy Korman, CNM
  • NRS 320
  • Foundations of Nursing Practice

2
Integumentary System
  • Nails
  • Hair
  • skin

3
Assessment Techniques
  • Inspection
  • Palpation
  • Olafactory

4
Functions of the Skin
  • Bodys External Protector
  • Regulation of body temperature
  • Sensory organ for pain, temperature, touch

5
Skin Assessment
  • Normal skin color is consistent with genetic
    background
  • Variations indicate some kind of problem
  • It is important to identify probable causes for
    skin to change its appearance
  • Skin is assessed for temperature, color,
    moisture, turgor, texture

6
Skin Assessment
  • Color normal skin color is consistent with
    genetic background. Variations that indicate
    problems include pallor, erythema, cyanosis and
    jaundice
  • Document the patients color as
  • Normal
  • Pale
  • Cyanotic
  • Flushed
  • jaundiced

7
What can cause these color changes?
  • Pallor
  • Eythema
  • Jaundice
  • Cyanosis

8
What can cause these color changes?
  • Pallor anxiety, anemia
  • Erythema carbon monoxide poisoning
  • Jaundice cirrhosis
  • Cyanosis hypoxemia

9
Assessing Dark-Skinned Patients
  • No matter what a patients race or ethnicity, the
    ability to note changes in skin color can mean
    life or death. Assessment can be difficult or
    inaccurate if you are unfamiliar with highly
    pigmented skin tones.

10
Assessing Dark-Skinned Patients
  • Adequate lighting-daylight is best
  • Establish a baseline for skin tone by observing
    least pigmented areas (palms, soles of feet,
    buttocks, volar surfaceof forearm, mouth,
    conjunctiva, nail beds)
  • Look for underlying reddish tone common to all
    skin

11
Skin Temperature
  • Temperature and other characteristics
  • Warm and dry?
  • Cool and clammy?
  • Diaphoretic?
  • Lesions? Wounds?
  • Normal ASsessment
  • Color normal, warm, dry and intact

12
What can cause these temperature changes?
  • Generalized coolness
  • Generalized warmth
  • Localized coolness
  • Localized hyperthermia

13
What can cause these temperature changes
  • Generalized coolness Hypothermia or cool down
    from OR
  • Generalized warmth Fever or increased metabolic
    rate
  • Localized coolness Poor circulation in the area,
    casts
  • Localized hyperthermia Infection, cut or surface
    wound

14
Assessing Moisture
  • Abnormal Skin Moisture
  • Diaphoresis may accompany chest pain, fever,
    anxiety
  • Dryness may present as dehydrated lips,
  • or as dry or cracked mucus membranes
  • Oiliness often causes acne

15
Assessing Texture
  • Skin may be rough, dry, scaly, thick
  • Skin may be very smooth, thin and moist (but not
    necessarily oily)
  • Red, scaly patches may indicate eczema (in
    infants may appear on cheeks or in diaper area)
  • Cradle cap manifests as greasy, yellow-brown
    patchs on scalp when not properly washed

16
Thyroid conditions
  • Hyperthyroidis Hypothyroidis
  • smooth dry
  • moist thick
  • warm pale
  • thin rough scaly
  • itchy

17
Wound Assessment
  • Wound
  • Type incision,laceration, skin tear,
    rash,perineal excoriation, decubitus
  • Appearance pink, red, eschar, sloughing,edematous
    , ecchymosis
  • Dressing open to air, changed, sterile, dry,or
    intact with sutures, staples, steristrips
  • Drainage serous, purulent, sanguinous, or none

18
Wounds with Eschar
19
Incisions
20
Bruising/Ecchymosis
  • Ecchymosis should be consistent with reported
    trauma. Bruising above the knees and below the
    elbows is suspicioius and may indicate abuse.
  • Photograph ecchymosis (ED)
  • The age of the ecchymosis can be determined by
    color

21
Assessing Skin Turgor
  • To determine turgor, pinch a fold of skin under
    the clavicle or on the forearm so the top skin
    separates from the underlying structure. Assess
    as follows
  • Normal rises easily and returns to place
    immediately
  • Abnormal skin does not return to place
    immediately but exhibits tenting

22
Assessing Turgor
  • Because poor skin turgor is more common and more
    prominent in the elderly patient due to loss of
    elasticity, check for skin turgor at the sternum.
  • Abnormal turgor is exhibited in dehydration,
    edema, scleroderma, connective tissue disorders

23
Assessing Lesions
  • Examine lesion color and elevation with a
    flashlight
  • Wear gloves to examine lesions
  • Record size (diameter) of lesions and surrounding
    erythema in centimeters

24
Assessing Lesions
  • Elevation
  • Flat?
  • Raised?
  • Pedunculated (connected to the skin on a stem or
    stalk-like base)

25
Assessing Lesions
  • Distrubution Symmetrical or asymmetrical
    distribution of lesions
  • Generalized (widely distributed)
  • Localized
  • Regional (specific to an area)

26
Assessing Pressure Ulcers
27
Stage One
  • Intact skin with non-blanchable redness of a
    localized area usually over a bony prominence

28
Stage Two
  • The epidermis or topmost layer of the skin is
    broken, creating a shallow open sore. Drainage
    may or may not be present.

29
Stage Three
  • Full thickness tissue loss. Subcutaneous fat may
    be visible but muscle, bone and tendon are not
    exposed. Slough may be present but does not
    obscure the depth of the tissue loss. May
    include undermining and tunneling.

30
Stage Four
  • Full thickness skin loss with extensive
    destruction, tissue necrosis, or damage to
    muscle, bone, or supporting structures.

31
Assessing IV Site
  • Note if IV is patent
  • Note location and type of catheter
  • Note if there is redness or edema
  • Note if the dressing is dry and intact
  • Note if IV site or dressing is changed
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