Lesson Objectives:

1. Review the anatomy & function of the skin.

2. Use correct techniques to perform a physical
assessment of the skin.
3. Teach a client on self- assessment of the skin.
4. Clearly document & communicate objective &
subjective data findings.
5. Recognize the different assessment findings.
Structure and Function of Skin

• The skin is a physical barrier that protects the

underlying tissues and structures from
microorganisms, physical trauma, ultraviolet
radiation, and dehydration.

• Vital role in temperature maintenance, fluid and

electrolyte balance, absorption, excretion, sensation,
immunity, and vitamin D synthesis.
Skin
SA – 1.2-2.2 m2 and weighs 4-5 kg (9-11 lbs)
Consists of three major regions
Epidermis: outermost region (superficial);epi = above
Resists abrasion
Reduces water loss
Composed of epithelial tissue
Dermis: middle region (bulk of skin)
Responsible for most of the structural strength of the skin
Leather is produced from the dermis of animals
Subcutaneous tissue (hypodermis): deepest region
Not really part of the skin
Connects the skin to underlying muscle or bone
Storage depot for fat and contains large blood vessels that supply
the skin
 Skin Color
• Melanocytes produce melanin inside melanosomes
and then transfer the melanin to keratinocytes
– The size and distribution of melanosomes determine skin
color
– Melanin production is determined genetically but can be
influenced by UV light (tanning) and hormones
SKIN
- Assessment of the skin includes inspection and
palpation

- But in some instances the nurse may also need

to use olfactory sense to detect unusual skin odors

- PUNGENT BODY ODOR is usually related to

poor hygiene
 EQUIPMENT:
Good lighting
Disposable gloves
Metric ruler
Mirror
Penlight
Examination gown or
drape
How to Examine your Own Skin

Face the Mirror

1. Check your face, ears, neck, chest and belly.
2. Check both sides of your arms, the tops of your
hands and palms and your nail beds.

Sit Down
3. Check the front of your thighs, shins, tops of your
feet, in between your toes, toenail beds, and bottoms
of your feet.
Stand Up
4. Now look at the back of your feet, your calves, and
the backs of your thighs- first one leg, then the other.
(You will need a hand mirror for the back of your
thighs.)
5. Use the hand mirror to check the buttocks, genital
are, lower back, upper back and the back of the
neck. (It may be helpful to look at your back in a
wall mirror by using hand mirror. )
 SKIN- Subjective Data
(Hx of Present Health
Concern)
Q: Are you experiencing any current skin problems
such as rashes, lesions, dryness, oiliness,
drainage, bruising, swelling, or increased
pigmentation? What aggravates the problem?
What relieves it?
RATIONALE: Any of these symptoms may be
related to a pathological skin condition. Bruises,
welts, or burns may indicate accidents or trauma
or abuse. If these injuries cannot be explained or
the clients explanation seems unbelievable or
vague, physical abuse should be suspected. Dry,
itchy skin is a common concern in obese clients.
 SKIN- Subjective Data
(History of Present Health Concern)
Q: Describe any birthmarks, tattoos or
moles you now have. Have any of them
changed color, size, or shape?

RATIONALE: You need to know what is normal for the

client so that future variations can be detected. A
change in the appearance or bleeding of any skin
mark, especially a mole, may indicate cancer.
 Assessment Normal Findings

INSPECTION: Inspection reveals

general skin evenly colored skin
coloration. Keep in tones without unusual
mind that the amount or prominent
of pigment in the skin discolorations.
accounts for the
intensity of color as
well as hue.
 ABNORMAL FINDINGS
PALLOR
- Is usually characterized by
the absence of underlying
red tones in the skin and
may be most readily seen in
the buccal mucosa
 Cyanosis
- Bluish tinged
- Most evident in the nail beds,
lips and buccal mucosa
- In dark skinned clients, close
inspection of the palpebral
conjunctiva and palms and soles
may also show evidence
 Jaundice
- yellowish tinged
- May be first evident in the sclera and in the
mucous membrane and the skin
 Erythema
- Is a redness of the skin related to a variety of
rashes and irritation
 NORMAL
Abnormal
FINDINGS Findings:
• While • Client has A strong odor of
inspecting skin slight or no perspiration or
color, note any odor of foul odor can
odors perspiration, indicate disorder
emanating from depending on of sweat glands.
the skin. activity. Poor hygiene
practices may
indicate a need
for client
teaching or
assistance with
ADL’s
 ASSESSMENT
PROCEDURE NORMAL FINDINGS

• Inspect for color variations.
inspect localized parts of the
body noting any color
variations.
Keep in mind that some clients have
suntanned areas, freckles, or white
patches known as vitiligo. These
variations are due to different amounts
of melanin in certain areas.
 ALBINISM
-Is the complete or partial lack of melanin
in
the skin, hair and nails
ASSESSMENT NORMAL
FINDINGS
Check skin
integrity.
Especially the Skin is normal
pressure points
(sacrum, hips, , and there are
elbows) no reddened
areas.

Abnormal Findings:
Skin breakdown is initially noted as
a reddened area in the skin that may
progress to serious and painful
pressure ulcers.
 NORMAL
ASSESSMENT
FINDINGS Abnormal Findings:

Inspect for lesions. Lesions may indicate

Smooth, local or systemic
Observe the skin without
surface to detect infection problems.
lesions. Stretch
abnormalities. Note marks, healed
color shape and size scars, freckles,
of lesion. For very moles or
small lesion, use a birthmarks are
magnifying glass to common
note these findings.
characteristics.
 ASSESSMENT NORMAL FINDINGS

Palpate skin to • Skin is smooth and even.

assess texture.
Use the palmar surface of your Abnormal Findings:
three middle fingers to Rough, flaky, dry skin is
palpate skin texture. seen in hypothyroidism.
 ASSESSMENT
Palpate to assess moisture.
Check under skin folds and in
unexposed areas.
NORMAL FINDINGS
Skin surfaces vary from
moist to dry depending
on the area assessed.
Recent activity or a
warm environment may
cause increased
pressure.

Abnormal Findings:
increased moisture or diaphoresis may occur in conditions such
as fever. Decreased moisture occurs with dehydration.
 Hyperhydrosis – excessive perspiration
Bromhidrosis – foul smelling perspiration
ASSESSMENT NORMAL Abnormal
FINDINGS Findings:
Palpate to assess
temperature.
Use the dorsal surfaces Cold skin may
Skin is
of your hands to accompany shock
normally
palpate the skin. warm in or hypotension.
temperature
.
ASSESSMENT NORMAL
Palpate to assess FINDINGS Abnormal Findings:
mobility.
Ask the client to lie
down. Using two Decreased mobility is
Skin goes back
fingers, gently pinch the seen with edema.
to its original
skin on the sternum or Decreased turgor (a
state after 2
under the clavicle. Check slow return of the skin
seconds
for mobility and turgor. to its normal state
taking longer than 3
seconds) is seen in
dehydration.
ASSESSMENT Abnormal
Palpate to detect NORMAL
Findings:
edema. FINDINGS
Use your thumbs
to press down on Indentations on the
the skin of the feet Skin rebounds and skin may vary
or ankle to check does not remain slight to great and
for edema ( 5-10 indented when may be in one area
sec press firmly pressure is or all over the
(swelling related released. body
to accumulation of
fluid in the tissue).
 Edema
Is the presence of
excess interstitial
fluid
An area of edema
appears swollen,
shiny and taut and
tends to blanch the
skin color
Most often it is an
indication of
impaired venous
circulation and in
some cases reflects
cardiac dysfunction
or vein abnormalities