Skin Assessment Notes

1) Perform general inspection of the skin and use palpation to assess for temperature, turgor, moisture. a) Skin: Color tan-pink, even pigmentation, with no suspicious nevi. Warm to touch, dry, smooth, and even. Turgor good, no lesions i) Detecting Color Changes in Light and Dar...

1) Perform general inspection of the skin and use palpation to assess for temperature, turgor, moisture. a) Skin: Color tan-pink, even pigmentation, with no suspicious nevi. Warm to touch, dry, smooth, and even. Turgor good, no lesions i) Detecting Color Changes in Light and Dark Skin: Look for pallor in dark-skinned people by the absence of the luster of the underlying red tones. The brown-skinned individual shows yellowish- brown color, and the black-skinned person appears ashen or gray b) Temperature: Palpate the skin it should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. i) Abnormal Findings: Hypothermia: Localized coolness is expected with an immobilized extremity, as when a limb is in a cast or with an intravenous infusion Hyperthermia: Generalized hyperthermia occurs with an increased metabolic rate such as in fever or after heavy exercise. EX: trauma, infection, or sunburn c) Turgor: Pinch up a large fold of skin on the anterior chest under the clavicle. Mobility is the ease of skin to rise, and turgor is its ability to return to place promptly when released. (elasticity of the skin) Returns in less than 2 seconds d) Moisture: Perspiration appears normally on the face, hands, axillae, and skinfolds. i) Abnormal Findings: Diaphoresis: sweating- increases metabolic rate Dehydration: look in the oral mucous membranes- normal is smooth and moist. ii) Dry skin (xerosis) is common in the aging person because of a decline in the number and output of the sweat glands and sebaceous glands. The skin itches and looks flaky and loose. 2) Describe the assessments of the scalp, hair, and nails. a) Scalp/ Hair: Even distribution, thick texture, no lesions or pest inhabitants b) Nails: No clubbing or deformities. Nail beds pink with prompt capillary refill. (1) The nail surface is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded. Nail edges are smooth, rounded, and clean, suggesting adequate self- care. (2) The nail base is firm to palpation (160) (3) The surface is smooth and regular, not brittle or splitting. (4) The translucent nail plate is a window to the even, pink nail bed underneath. ii) Capillary Refills: depress the nail edge at least 5 seconds to blanch and then release. Normal peripheral circulation is 1-2 seconds 3) Distinguish between normal and abnormal findings of the integumentary exam and use appropriate terminology to document findings. 4) Demonstrate appropriate assessment and evaluation for common hospital skin concerns including pressure and edema. i) Pressure Injuries/Ulcers: Over bony prominences. Risk factors are impaired mobility, thin fragile skin of aging, decreased sensory perception, impaired level of consciousness, moisture, poor nutrition & infection.  (1) Stage 1: Non- Blanchable Erythema- intact skin is red but broken (2) Stage 2: Partial Thickness Skin Loss- loss of epidermis and exposed dermis (3) Stage 3: Full Thickness Skin Loss- subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon (4) Stage 4: Full thickness Skin/ Tissue Loss- Exposes muscle, tendon, or bone, and may show slough or eschar (black or brown necrotic tissue), rolled edges, and tunneling. ii) Edema: fluid accumulating in the interstitial spaces. To check for edema, imprint your thumbs firmly for 3 to 4 seconds against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If your pressure leaves a dent in the skin, “pitting” edema is present. (1) 1+, Mild pitting, slight indentation, no perceptible swelling of the leg 2+, Moderate pitting, indentation subsides rapidly 3+, Deep pitting, indentation remains for a short time 4+, Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted 5) Describe the appropriate nursing actions for any abnormal findings.