Physical Skin

Assessment
 Outlines:

 Introduction

 Anatomy of the skin

 Physical assessment of normal skin

 Common abnormal lesions of the skin

Introduction

 The skin is the largest organ in the body; The external surface

of the body ,it serves as a barrier between a person’s outer and

inner surroundings. Skin reflects general health of the body.

About 16% of an adult's total body weight.

 Function of the skin
 Appearance - reflects general health of the body.

 Protection: against pathogens. Langerhans cells in the skin are part of the

immune system.

 Storage: stores lipids (fats) and water.

 Sensation: nerve endings detect temperature, pressure, vibration, touch, and

injury.

 Control water loss: the skin prevents water from escaping by evaporation.

 Thermoregulation
 Structure of the Skin
1-Epidermis

Two main
parts:

2-Dermis.
 2-Dermis
1-Epidermis

 superficial  Deeper

 thinner  thicker

 epithelial tissue  connective tissue

 Subcutaneous layer (subQ)

 Also called the hypodermis.

 Deep to the dermis, but not part of the skin..

 Attaches skin to underlying tissues and organs

 Accessory Structures of the Skin

Hair Skin gland

Nails
 Physical Assessment of Skin
o Patient preparation:

o Explain procedures and answer any questions.

o Conduct the assessment in private space , and maintain privacy.

o Ask the patient to remove all clothing and to put on an examination gown.

o Make sure the patient in comfortable position, and comfortable temperature room.

o Sunlight is best for inspecting the skin.

o Wash hand and Wear gloves.

o Ask help to turn the patient as needed.

o Inspect for generalized color

• Pallor (loss of color) is seen in arterial insufficiency, decreased blood

supply and anemia.

• Cyanosis (bluish or grayish discoloration) occurs with

vasoconstriction, MI, or pulmonary insufficiency.

• Jaundice, a condition characterized by yellowness of the skin, is seen

in liver or gallbladder disease. This may be seen in the sclera, oral

mucous membranes, palms and soles.

 jaundice
 Jaundice is a condition in which the skin, sclera (whites of the eyes) and mucous

membranes turn yellow. This yellow color is caused by a high level of bilirubin,

a yellow-orange bile pigment. Bile is fluid secreted by the liver. Bilirubin is

formed from the breakdown of red blood cells this indicate for liver dysfunction.
Cyanosis

 Cyanosis is defined as a bluish discoloration, especially of the skin and

mucous membranes, due to excessive concentration of deoxyhemoglobin

in the blood caused by DE oxygenation. Cyanosis is divided into two main

types: central (around the core, lips, and tongue) and peripheral (only the

extremities or fingers this indicate for hypoxemia.

Ecchymosis

 A discoloration of the skin resulting from bleeding underneath, typically

caused by bruising.

Petechiae

 Petechiae are tiny purple, red, or brown spots on the skin. They usually
appear on your arms, legs, stomach, and buttocks.
Inspect for skin integrity

 Check carefully in pressure point areas (e.g., sacrum, hips, elbows) for skin

integrity.

 Skin is intact and there are no reddened areas.

 Skin breakdown is initially noted as a reddened area on the skin that may

progress to serious and painful ulcers.

o Inspect for lesions

 Inspect all areas for lesions.

- Note color.

- Elevation or depression.

- Shape, location, distribution.

- Size of lesion and any exudates.

• For very small lesions, use a magnifying glass to note these

characteristics.

• Smooth, without lesions.

 Stretch marks (striae), healed scars, freckles are normal findings

o Palpate for texture

o Use the palmer surface of the three middle fingers to palpate skin

texture.

o Skin is smooth and flat.

o Rough, flaky, dry skin is seen in hypothyroidism and dehydration.

o Palpate for thickness

• Use the finger pads to palpate for skin thickness.

• Skin is normally thin.

o Palpate for temperature

• Use the dorsal surfaces of the hands to palpate the skin.

 Skin is normally a warm temperature
o Palpate for moisture

 unexposed areas. Use the dorsal surfaces of the hands to assess for

moisture.

 Check under skin folds and in

 Varies from moist to dry depending on area assessed

o Palpate for mobility and turgor

 Mobility refers to how easily the skin can be pinched.

 Turgor refers to the skin’s elasticity and how quickly the skin returns to its original

shape after being pinched.

 Ask the patient to lie down.

 Use two fingers (thumb and forefinger) to pinch up the skin on the sternum or

under the clavicle, or forearm.

 Skin pinches easily and immediately returns to its original position.

o Palpate for edema

 Use the thumbs to press down on the skin of the feet or ankles to check
for edema.
 Skin does not remain indented when pressure is released.
 Skin indentation may from slight to great and may be in one area or all
over the body.
 What Is Edema?
 Edema" is the medical term for swelling. Body parts swell from injury

or inflammation . It can affect a small area or the entire

body. Medications, pregnancy, infections, and many other medical

problems can cause edema.

 Edema happens when your small blood vessels leak fluid into nearby

tissues. That extra fluid builds up, which makes the tissue swell. It can

happen almost anywhere in the body

 Classification of edema
 According to the site of edema

1) Localized edema

2) Generalized edema (anasarca)

 According to consistency of edema:

1) Pitting edema (Soft edema)

 Non-Pitting edema (Hard edema

 Localized edema Localized in a part of the body.

The total amount of fluids in the body is within normal but with abnormal

distribution It includes

 Inflammatory edema: Occurs in acute inflammation. The edema fluid is an

exudate.

 Obstructive edema: Venous obstruction → ↑ hydrostatic pressure in the

veins and capillaries → edema Lymphatic obstruction

Generalized edema (anasarca)

The total amount of body fluids is increased. It includes

 Cardiac edema: Occurs in congestive heart failure

 Nutritional edema: Caused by hypoproteinemia due to:- Malnutrition &

Malabsorption states- Chronic liver disease → ↓ formation of plasma

proteins

 Renal edema: Occurs in renal diseases & is of two types:- Nephritic

edema: Occurs in acute diffuse glomerulonephritis.- Nephrotic edema: It

is caused by massive albuminuria → hypoproteinemia

 Assessment of Nails

Inspect for grooming and cleanlines

 Normal findings Clean

 Abnormal findings Dirty, broken or jagged fingernails may be seen with

poor hygiene or depression.

 They may also result from the patient’s hobby or occupation

Inspect for color and markings

 Normal findings Pink tones.

 Some longitudinal ridging is normal

 Abnormal findings Pale or cyanotic nails may indicate hypoxia or

anemia.

 Splinter hemorrhages may be caused by trauma

 Yellow discoloration may be seen in fungal infections or psoriasis.

 Nail pitting is common in psoriasis.

 Inspect for shape

o Assessment procedure View the index finger at its profile and note the

angle of the nail base.

 Normal findings There is normally a 160 angle between the nail base and

the skin. Nail surface is Slightly curved, Nail edge is are smooth rounded

clean.
 Abnormal findings

 Early clubbing (180 angle with spongy sensation) and late clubbing (greater than

180 angle) can occur from hypoxia.

 Koilonychias: refers to thin, Spoon nails with lateral edges that tilt upward,

forming a concave profile. The nails are white and opaque.

 this condition is associated with hypochromic anemia, chronic infections,

raynaud’s disease and malnutrition.

 In late clubbing, the now convex nail bases can touch without leaving a space.

This condition is associated with pulmonary and cardiovascular disease such as

emphysema, chronic bronchitis, lung cancer and heart failure.

Inspect for texture

 Normal Nails are hard and basically immobile.

 Older patient’s nails may appear thickened, yellow and brittle because of

decreased circulation in the extremities

 Abnormal findings

 Thickened nails (especially toenails) may be caused by decreased

circulation
Palpate for consistency

 Note whether nail plate is attached to nail bed.

 Normal finding

 Smooth, regular and firm.

 Nail plate firmly attached to nail bed.

 Abnormal finding Paronychia (inflammation) indicates local infection.

 Detachment of nail plate from nail bed (Onycholysis) is seen in infections

or trauma
Paronychia
 Common abnormal lesion of the skin

 Skin lesions are an abnormal change of the skin compared to the

surrounding tissue. They may be something you are born with or

something you acquire. They can be benign or severe, generalized or

localized, symmetrical or irregular.

 A skin lesion's physical characteristics—including color, size, texture,

and location—can be used to help establish if there is an underlying

cause. Skin lesions are broadly classified as being either primary or

secondary.
 Primary Lesions
 Primary skin lesions are either present from birth or develop over your

lifetime. They are associated with a specific cause or can be a reaction to either

internal or external environments. They tend to be divided into three types of

groups:

 Skin lesions formed by fluid within the skin layers, such as vesicles or

pustules.

 Skin lesions that are solid, palpable, masses, such as nodules or tumors.

 Flat, non-palpable skin lesions like patches and macules

 Types of primary lesion include:
 Bulla: A vesicle that is greater than 0.5 centimeters (cm) or 1/5 of an inch

and filled with fluid

 Cyst: A raised, circumscribed area of the skin, filled with fluid or semi-
solid fluid
 Macule: A non-palpable, flat lesion that is different in color, and less than 0.5cm
in size

 Papule (also maculopapular): An elevated solid lesion, up to 0.5 cm in size,

circumscribed and firm. It can appear in various colors
 Patch: A non-palpable, flat lesion that is different in color and greater than
0.5 cm in size

 Plaque: Greater than 1-2 cm in diameter, raised like a papule, solid, rough,
and flat-topped
 Vesicle: A fluid-filled blister less than 0.5 cm in size

 Pustule: Similar to a vesicle but filled with pus instead of fluid

 Nodule: A circular, elevated, solid bump of greater than 0.5

 Telangiectasia: Clusters of 'spider veins' where tiny blood vessels cause red
lines on the skin

 Tumor: Is larger than 0.5 cm but similar to a nodule in appearance. They can
be benign or malignant

 Wheal: An irregular- shaped, solid, elevated area that can vary in color and is
transient
 Secondary Lesions

 Secondary skin lesions are caused when a primary skin lesion

is disturbed, irritated, or changes over time. For example, if

eczema is scratched and causes a crust to form, the crust is a

secondary lesion
 Examples of secondary skin lesions
include:
 Atrophy: Occurs when skin becomes paper-thin, transparent, and
wrinkled, usually due to the use of a topic agent like topical steroids.

 Crust: A rough, elevated area formed from dried fluid (which can be pus,
blood, or serum)
 Erosion: Loss of the epidermis, moist and glistening in appearance

 Excoriation: Linear scratches that result in the loss of epidermis

 Fissure: Linear breaks in the skin that go deeper than the epidermis into

the dermis. They can be painful and can be caused by excessive dryness.

 Lichenification: A rough, thickening of the epidermis

 Maceration: This is when skin becomes wet, wrinkly, and lighter in color

due to being in contact with water or fluid for too long. This can occur due

to leaking wounds due to improper wound care.

 Phyma: A thickening of the skin, often seen in advanced rosacea 2

 Scale: A build-up of keratinized cells that form patches and then flake off

the skin

 Ulcer: A wound deeper than the epidermis, damaging the dermis, concave,

variable in size, and graded depending on depth

 Umbilication: A dip inside a skin lesion that looks similar to a navel

Reference:
 Baid, H. (2006). Patient assessment. The process of conducting a physical

assessment: a nursing perspective. British Journal Of Nursing, 15(13), 710-714.

 Bickley, L. S., Szilagyi, P. G., & Bates, B. (2009). Bates' guide to physical

examination and history taking (10th ed.): Philadelphia : Wolters Kluwer

Health/Lippincott Williams & Wilkins, .

 Brocato, C. (2009). A lot of nerve: how to perform a full neurological assessment for

medical & trauma patients. JEMS: Journal of Emergency Medical Services, 34(3),

72-72-75, 77, 79-82 passim. doi: 10.1016/s0197-2510(09)70074-9