RN HealthAssess 3.0 - Skin

• Skin assessment can be part of a full physical or a focused visit.
• Understand the reason for the visit and the client's expectations.
• Techniques used for a skin assessment include inspection and palpation.
• Inspect for color, texture, moisture, and integrity.
• Palpate for texture, moisture, temperature, mobility, and turgor.
• Assessing the client's fingernails and toenails is part of the inspection.
• Discuss client participation, like raising arms or removing shoes and socks.
• Instructions about self-care, prevention, and monitoring should be personalized.
• Documentation captures clinical impressions and serves as a baseline.

Tools for Assessment

• Penlight: For closer examination and direct lighting.
• Gloves: Wear gloves if moisture, weeping, or bleeding is present for infection control.
• Ruler: Use a centimeter ruler to measure unexpected findings.

Anatomy of the Skin

• The skin is constituted of three layers; epidermis, dermis, and subcutaneous.
• Epidermis: Outermost layer with keratin and melanocytes (pigment).
• Dermis: Middle layer with collagen, blood vessels, nerves, hair follicles, and sensory receptors.
• Subcutaneous Layer: Bottom layer with adipose tissue for temperature regulation and cushioning.

Nails

• Clear hard plates of keratin.
• Nail bed grows outward from the nail root.

Physiology

• Functions of skin and nails include:
  • Protecting inner body parts.
  • Body temperature regulation.
  • Sensory perception.
  • Excreting waste.
  • Producing vitamin D.
• Vitamin D is necessary for calcium absorption and comes from sunlight, food, and supplements.

Health History Interview

• Interview the client about their skin and nails health history to collect subjective data.
• Clinical questions include:
  • History of allergies, rashes, or skin problems?
  • Problems or changes with skin or nails?
  • Itching, bruising, lumps, rashes, scars, open sores, or lesions?
  • Skin and nail care practices?
  • Personal or family history of skin cancer?
  • Self-assessment of moles and lesions?

Case Study

• Priority reasons for further investigation include:
  • Itching keeping the client awake at night with a pain level of 8.
  • Worsening rash despite treatment.

Skin Color

• Skin color should be even and consistent with genetic background.
• Skin color comes from melanin (brown), carotene (yellow), and blood vessels (red).
• Increased blood flow areas (cheeks, chest, genitals) often have increased reddened tones.
• Darker skin tones have lighter pigmentation on palms and soles.

Expected Variations in Skin Color

• Hyperpigmentation occurs when melanin is increased:
  • Birthmarks.
  • Sun damage.
  • Pregnancy changes (chloasma or melasma).
  • Solar lentigines (age or liver spots).
  • Cafe au lait spots.
  • Tan lines.
• Hypopigmentation occurs when melanin is decreased:
  • Scars.
  • Stretch marks.
  • Vitiligo (lack of melanin pigment in patches).

Unexpected Findings in Skin Color

• Cyanosis: Bluish color due to lack of oxygen; observe oral mucosa and nail beds in darker skin.
• Ecchymosis: Bruises from bleeding under the skin; appear as blotches.
• Petechiae: Small purple or red spots due to tiny hemorrhages.
• Erythema: Redness caused by inflammation; purplish tinge in darker skin tones (difficult to detect).
• Jaundice: Yellowish color due to increased bilirubin; observe sclera, hard palate, palms, and soles.
• Pallor: Pale color; yellow-brown to dull grey in darker skin tones, white in lighter skin tones; observe lips, mucous membranes, and nail beds.

Skin Texture and Moisture

• Skin should be smooth and uniformly dry.
• Xerosis: Dry skin due to very little lubricant.
• Seborrhea: Oily skin due to a lot of lubricant.

Expected Variations in Texture and Moisture

• Acne: Blackheads, whiteheads, pimples, oily skin, scarring; stress and puberty can trigger it.
• Wrinkles: Epidermis thins, skin oil decreases, elasticity decreases with aging.
• Scars: Fibrous tissue from healed lesions or injuries; may be thin or wide; atrophic scars (striae or stretch marks) and keloids (overgrowth of scar tissue).

Unexpected Findings in Texture and Moisture

• Velvety Skin: Extremely smooth could signal thyroid disease.
• Roughness, Dryness, Flakiness: Could indicate skin irritation, trauma, thyroid disease, or dehydration.
• Diaphoresis: Excessive perspiration due to fever, thyroid disorders, increased activity, shock, pain, or anxiety; pallor with diaphoresis can indicate heart failure.

Skin Integrity

• Skin should be smooth and intact generally.

Unexpected Findings in Skin Integrity

• Lesions: Alterations to skin integrity due to variations, trauma, or disease.
• Lesion characteristics: Color, height, shape, size (cm), location, drainage (color and odor).

Types of Skin Lesions

• Vascular Lesions result from blood leaking from the blood vessels into the dermis. These lesions can occur because of trauma, infections or a disease process:
  • Petechiae: Small (1-3 mm) reddish-purple spots due to infection or trauma.
  • Ecchymosis: Collection of blood (>3 mm) in the dermis, changing from reddish-purple to blue or yellow due to trauma.
  • Purpura: Collection of petechiae and ecchymosis covering an area due to infection or bleeding disorder.
• Primary Lesions: Result from a specific triggering agent on intact skin:
  • Macule: Small (<1 cm) area of pigmentation change; example freckle.
  • Patch: Larger (>1 cm) area of pigmentation change; example birthmark, vitiligo.
  • Papule: Small (<1 cm) solid area; example wart, elevated mole.
  • Plaque: Large (>1 cm) disc-shaped area; example psoriasis, eczema.
  • Wheal: Irregular area of edema; example insect bites, allergic reaction.
  • Nodule: Small (<2 cm) firm area from deeper in the dermis; example melanoma.
  • Tumor: Large (>2 cm) firm area from deeper in the dermis; example lipoma.
  • Vesicle: Small (<1 cm) fluid-filled superficial; example varicella (chicken pox).
  • Bulla: Large (>1 cm) fluid-filled superficial; example blister.
  • Pustule: Small (<1 cm) pus-filled superficial; example acne, herpes simplex.
  • Cyst: Encapsulated fluid-filled area from dermis or subcutaneous layer; example cystic acne.
• Secondary Lesions: Evolved from primary lesions:
  • Lichenification: Thickened skin from long-term scratching; chronic skin inflammation.
  • Crust: Dried exudate; example scab.
  • Scale: Excessive shedding of keratin cells; example psoriasis.
  • Fissure: Straight crack into the dermis; example cheilosis.
  • Erosion: Shallow depression in the epidermis; example varicella.
  • Ulceration: Deeper depression with loss of epidermis and dermis; example pressure injury.
  • Excoriation: Loss of epidermis in linear crusted areas; example abrasions.
• Potentially Malignant Lesions: Changes indicating skin cancer, linked to UV exposure

ABCDE Rule for Suspicious Lesions

• Used for pigmented lesions.
  • Asymmetry: One side doesn't match the other.
  • Border: Irregular, notching, or blurred.
  • Color: Variation within the lesion.
  • Diameter: Greater than 6 mm.
  • Evolving: Rapid change in size, symptoms, or composition.
• "Ugly Duckling" Method: Identifying moles that look different from others.

Intervention Needed: Pressure Injuries

• Tissue damage due to impaired circulation over bony prominences
• Risk factors:
  • Limited mobility
  • Thin skin
  • Poor nutrition
  • Moisture
  • Friction
• Assessment:
  • Assess skin pressure points with limited mobility every four hours.
• Stages:
  • Stage I: Reddened area that doesn't blanch, texture or temperature change.
  • Stage II: Partial dermis loss, shiny or dry ulcer with pink wound bed.
  • Stage III: Full-thickness skin loss, subcutaneous tissue damage, possible dead tissue.
  • Stage IV: Full-thickness skin loss, exposed bones, tendons, or muscle, possible dead tissue.
• Measure weekly to monitor healing, and measure the largest dimension of the wound.
• Monitor the wound for signs of infection and changes in the appearance.
• Assess for fever, chills, and increased pain, which can signify the presence of a bone infection.
• Interventions:
  • Inspect skin frequently.
  • Reposition every 2 hours.
  • Elevate the head of the bed less than 30°.
  • Remove sources of moisture.
  • Provide dietary supplements.
  • Don't rub reddened areas.
  • Provide wound care.
  • Use a lift device.
• Documentation:
  • Location.
  • Size.
  • Depth.
  • Appearance.
  • Drainage.

Skin Temperature

• Skin should feel as warm as your hands consistently across the body.
• Variations:
  • Extremities may be cooler in cold environments or with circulation problems.
• Unexpected Findings:
  • Hyperthermia: Elevated temperature indicates fever or localized inflammation.
  • Hypothermia: Cool temperature indicates poor perfusion or decreased blood flow.

Skin Mobility and Turgor

• Expected: Skin rises easily when pinched and returns rapidly to its flat position.
• Variations: Delayed return in older clients due to decreased elasticity.
• Unexpected:
  • Tenting: Skin remains elevated after release, indicating weight loss or dehydration.
  • Edema: Decreased mobility due to fluid accumulation, inspect for swelling and palpate for pitting.

Nails

• Expected Findings:
  • Slightly curved or flat.
  • Smooth, rounded base edges.
  • Uniform thickness.
  • Translucent with color similar to skin tone.
  • Capillary refill less than 2 seconds.
• Variations:
  • Slower growth.
  • Thicker nails in older adults.
  • Uneven ridges from healed injuries.
  • Brittle or peeling layers.
  • Yellow color.
• Unexpected Findings:
  • Color Variations: Brown streaks, bluish tinge (cyanosis), whitish (pallor).
  • Clubbed Nails: Spongy nail base, spoon-like appearance, wider fingertips; related to heart or pulmonary diseases.
  • Jagged Nails: Uneven edges from biting or brittleness.
  • Structure Variations: Thick rigid nails, pits or depressed areas, transverse grooves.
  • Delayed Capillary Refill: Indicates peripheral blood vessel or respiratory problems.

Health Promotion

• Bathing and Hygiene Practices:
  • Remove oil, sweat, dead skin cells, and bacteria.
  • Promotes circulation.
  • Comfortable water temperature: 43°C to 46°C (110°F to 115°F).
  • Alcohol-free and perfume-free products reduce irritation.
  • Discard eye makeup after 4 months to prevent infections.
  • Abrasions: Keep clean and dry, check bandages for moisture.
  • Excessive Skin Dryness: Use alcohol-free lotions, bathe less frequently, drink more fluids, wear cotton clothing.
  • Acne: Keep skin clean, wash daily, use oily cosmetics sparingly, avoid squeezing lesions.
  • Erythema: Wash carefully, use antiseptic spray.
• Skin Protection From Sun Exposure:
  • Environmental risk for skin cancer is exposure to ultraviolet radiation from the sun.
  • Apply broad-spectrum sunscreen (SPF 30 or greater) 15 minutes before going outdoors.
  • Reapply after swimming or sweating.
  • Use wide-brimmed hats and sun-protective clothing.
  • Limit sun exposure, especially from 10 a.m. to 4 p.m.
  • Avoid indoor tanning equipment.
• Self-Assessment of Moles and Suspicious Lesions:
  • Risk Factors: UV exposure, family history, moles, light skin, immunosuppression, previous skin cancer.

Subjective Finding

• The patient's statement "I don't get around very well" is considered a subjective finding because it represents the client's personal experience and perception.

Objective Assessment of the Lower Extremities

• Documentation that includes observable, measurable, and factual information, without interpretation or personal opinions, such as " Erythema and hyperthermia noted on bilateral lower extremities with +4 pitting edema below the knees. Ulcerated area noted on bilateral mid shin areas: Left measures 3 x 3 cm, right measures 2 x 2 cm. Small amount of yellow drainage noted from both wounds." provides the most accurate information.

Learn skin assessment techniques, including inspection and palpation. Understand how to assess skin color, texture, moisture, and integrity. Discover the tools needed, such as penlights and rulers, and the basic anatomy of the skin's layers.