Download NRS 102 Skin Assessment

Denise Coffey MSN, RN
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Structure and Function
Subjective Data—Health History Questions
Objective Data—The Physical Exam
Abnormal Findings
Slide 12-2
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Skin—three layers
1. Epidermis
 Stratum germinativum or
basal cell layer
 Stratum corneum or
horny cell layer
 Derivation of skin color
2. Dermis
 Connective tissue or
collagen
 Elastic tissue
3. Subcutaneous layer
Slide 12-3
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Epidermal appendages
1. Hair
2. Sebaceous glands
3. Sweat glands
 Eccrine glands
 Apocrine glands
4. Nails
Slide 12-4
Slide 12-5
Protection
 Prevents penetration
 Perception
 Temperature regulation
 Identification
 Communication
 Wound repair
 Absorption and excretion
 Production of vitamin D
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Slide 12-6
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Slide 12-7
Previous history of skin disease
(allergies, hives, psoriasis, or eczema)
Change in mole
Change in pigmentation (size or color)
Excessive dryness or moisture
Pruritus
Excessive bruising
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Preparation
 External variables that influence skin color
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Equipment needed
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Strong direct lighting
Small centimeter ruler
Penlight
Gloves
For special procedures
▪ Magnifying glass
▪ Materials for laboratory tests: glass slide
Slide 12-8
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Skin—Inspect and palpate
Color
 General pigmentation
 Widespread color change
▪ Pallor
▪ Erythema
▪ Cyanosis
▪ Jaundice
Slide 12-9
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Skin—Inspect and palpate (cont.)
Temperature
 Hypothermia
 Hyperthermia
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Moisture
 Diaphoresis
 Dehydration
Slide 12-10
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Skin—Inspect and palpate (cont.)
Texture
Thickness
Edema
Mobility and turgor
Vascularity or bruising
Slide 12-11
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Skin—Inspect and palpate (cont.)
Lesions
 Color
 Elevation
 Pattern or shape
 Size
 Location and distribution on body
 Exudate
Slide 12-12
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Promoting health and self-care
Teach skin self-examination, using the
ABCDE rule
 A—asymmetry
 B—border
 C—color
 D—diameter
 E—elevation and enlargement
Slide 12-13
Slide 12-14
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Hemangiomas
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 Port-wine stain
 Petechiae
(nevus flammeus)
 Strawberry mark
(immature hemangioma)
 Cavernous hemangioma
(mature)
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Purpuric lesions
 Purpura
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Lesions caused by
trauma or abuse
 Pattern injury
Telangiectases
 Hematoma
 Spider or star angioma
 Ecchymosis (bruise)
 Venous lake
Slide 12-15
Slide 12-16
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Diaper dermatitis
Interigo (candidiasis)
Impetigo
Atopic dermatitis (eczema)
Measles (rubeola)
German measles (rubella)
Chickenpox (varicella)
Slide 12-17
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Primary contact dermatitis
Allergic drug reaction
Tinea corporis (ringworm of the body)
Tinea pedis (ringworm of the foot)
Psoriasis
Tinea versicolor
Labial herpes simplex (cold sores)
Herpes zoster (shingles)
Erythema migrans of Lyme disease
Slide 12-18
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Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Slide 12-19
A.
B.
C.
D.
Slide 12-20
Cyanosis
Flushing
Rubor
Jaundice