PHYSICAL ASSESSMENT: SKIN
Take a thorough history
Obtain a history of the patient's skin condition
from the patient, caregiver, or previous medical
records. Go over the detailed family history with
the patient or patient's family, and make sure all
skin conditions are reviewed.
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Also obtain a history of the patient's bathing
routine and skin care products. Document the
soaps, shampoos, conditioners, lotions, oils, and
other topical products that the patient uses
routinely. Ask the patient:
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about skin changes such as xerosis (skin
dryness), pruritus, wounds, rashes, or
changes in skin pigmentation or color
if skin appearance changes with the
seasons
about any changes in nail thickness,
splitting, discoloration, breaking, and
separation from the nail bed. A change in
the patient's nails may be a sign of a
systemic condition.
about allergies, including those to
medications, topical skin and wound
products, and food.
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Document your findings in the medical record.
Perform a physical assessment
This includes assessment of skin color, moisture,
temperature, texture, mobility and turgor, and
skin lesions. Inspect and palpate the fingernails
and toenails, noting their color and shape and
whether any lesions are present.
Skin lesions can be categorized as primary or
secondary, although the distinction isn't always
clear. Make sure you use the correct term to
describe any lesions you find.
The following are primary lesions:
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macule, a flat, nonpalpable circumscribed
area (up to 1 cm) of color change that's
brown, red, white, or tan
patch, a flat, nonpalpable lesion with
changes in skin color, 1 cm or larger
papule, an elevated, palpable, firm,
circumscribed lesion up to 1 cm
plaque, an elevated, flat-topped, firm,
rough, superficial lesion 1 cm or larger,
often formed by coalescence of papules
nodule, an elevated, firm, circumscribed,
palpable area larger than 0.5 cm; it's
typically deeper and firmer than a papule
cyst, a nodule filled with an expressible
liquid or semisolid material
vesicle,
a
palpable,
elevated,
circumscribed,
superficial,
fluid-filled
blister up to 1 cm
bulla, a vesicle 1 cm or larger, filled with
serous fluid
pustule, which is elevated and superficial,
similar to a vesicle, but is filled with pus
wheal, a relatively transient, elevated,
irregularly shaped area of localized skin
edema. Most wheals are red, pale pink, or
white.
Secondary lesions can be caused by disease
progression, overtreatment, excessive scratching,
or infection of a primary lesion:
● scale, a thin flake of dead exfoliated
epidermis
● crust, the dried residue of skin exudates
such as serum, pus, or blood
● lichenification, visible and palpable
thickening
of
the
epidermis and
roughening of the skin with increased
visibility of the normal skin furrows (often
from chronic rubbing)
● excoriation, linear or punctuate loss of
epidermis, usually due to scratching.
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Standard Protocol for
Comprehensive Skin Assessment
Pay special attention to—
● Skin beneath and around any devices or
compression stockings
● Bony prominences (heels, sacrum, occiput)
● Skin to skin areas, such as the penis, back of
knees, inner thighs, and buttocks
● All areas where the patient —
– Lacks sensation to feel pain
– Had a breakdown previously
● Also pay special attention if the patient is
getting epidural/spinal pain medicines.
5 Parameters of Comprehensive
Skin Assessment
1. Temperature
2. Turgor (firmness)
3. Color 4. Moisture level
5. Skin integrity
– Skin intact
– Open areas, rashes, etc.
Parameter 1: Skin Temperature
● Palpate with your hand to assess skin
temperature.
● Skin warmth or coolness can indicate skin
damage, including—
– Stage I pressure ulcer
– Suspected deep tissue injury
– Preulceration in the diabetic foot
– Inflammation or infection
Parameter 2: Skin Turgor (Firmness)
● Skin normally returns to its original state
quickly when stretched.
● Can you “tent” the skin?
● Skin may be slow to return to its original
shape in older or dehydrated patients.
Parameter 3: Skin Color
● Compare adjacent areas of skin for color.
● Redness can indicate many skin problems—
– Pressure ulcer
– Rash
– Infection, cellulitis
● Deficiencies can also affect skin:
– Vitamin C deficiency causes purplish
blotches on lightly traumatized
areas.
– Zinc deficiency causes redness of
the nasolabial fold and eyebrows.
● Blanchable versus nonblanchable erythema
● Purple or bruised looking skin
Paper-thin skin
● Dark or reddened areas
Darkly pigmented skin does not blanch.
Redness
● Reddened skin on the sacral area can
be from a variety of etiologies.
● Make sure to get the etiology right so
you can treat the cause appropriately.
Parameter 4: Skin Moisture
Moisture-associated skin damage:
● •Skin can be dry (verosis) or damaged
from too much wetness (maceration).
● Etiology can be—
– Incontinence, urine, stool, or both
– Wound exudate
– Perspiration, including patients
with a fever
– Between skin folds (especially in
bariatric patients)
– Ostomy or fistula that leaks
● Make sure to get the etiology right so
you can treat the cause appropriately.
Parameter 5: Skin Integrity
● Skin should be intact.
● If skin is not intact, identify the etiology
of the skin problem.
● Etiology could be—
– Pressure
– Peripheral vascular (venous or
arterial)
– Neuropathic/diabetic
– Skin tears (especially forearm of
older adults)
– Trauma
● Make sure to get the etiology right so
you can treat the cause appropriately.
PHYSICAL ASSESSMENT: NAILS
Before assessing the nails ask if the patient:
● has had any recent trauma. A blow to the
nail changes the shape and growth of the
nail, as well as loss of all or parts of the
nail plate.
● have the patient also describe nail care
practices. Improper care damages nails
and cuticles. It is also important to find out
if patients have acrylic nails or silk wraps,
because these are areas for fungal
growth.
● question whether the patient has noticed
changes in nail appearance or growth.
Alterations occur slowly over time.
● knowing if the patient has risks for nail or
foot problems will influence the level of
hygienic care recommended.
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Splinter hemorrhage: red or brown linear
streaks in nail bed. Causes: minor trauma,
subacute
bacterial
endocarditis,
trichinosis.
Paronychia: inflammation of skin at base
of nail. Causes: local infection, trauma.
Inspect:
● the nail bed color
● the thickness and shape of the nail.
● the texture of the nail; and
● the condition of tissue around the nail.
The nails are normally transparent, smooth and
convex, with surrounding cuticles smooth, intact,
and without inflammation.
— In whites, nail beds are pink with
translucent white tips.
— In the dark- skinned patients, nail beds
are darkly pigmented with a blue or
reddish hue.
Abnormalities in the nail bed
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Normal nail: approximately 160 degree
angle between nail plate and nail.
Clubbing: change in angle between nail
and nail base (eventually larger than 180
degrees); nail bed softening, with nail
flattening; often, enlargement of fingertips
Causes: chronic lack of oxygen: heart or
pulmonary disease.
Beau’s lines: transverse depressions in
nails indicating temporary disturbance of
nail growth (nail grows out over several
months) Causes: systematic illness such as
severe infection, nail injury.
Koilonychia (spoon nail): concave curves.
Causes: iron deficiency anemia, syphilis,
use of strong detergents.
Procedure notes:
● Failure of the pinkness to return promptly
indicates circulatory insufficiency.
● An ongoing bluish or purplish cast to the
nail bed occurs with cyanosis.
● A white cast pallor results from anemia.
Calluses and corns often occur on the toes
or fingers.
● A callusis flat and painless, resulting from
thickening of the epidermis.
● Friction and pressure from shoes causes
corns, usually over bonyprominences.
● During the examination, instruct the
patient inproper nail care.
PHYSICAL ASSESSMENT: HAIR
Before assessing the nails ask if the patient:
● has had any recent trauma. A blow to the
nail changes the shape and growth of the
nail, as well as loss of all or parts of the
nail plate.
● have the patient also describe nail care
practices. Improper care damages nails
and cuticles. It is also important to find out
if patients have acrylic nails or silk wraps,
because these are areas for fungal
growth.
● question whether the patient has noticed
changes in nail appearance or growth.
Alterations occur slowly over time.
● knowing if the patient has risks for nail or
foot problems will influence the level of
hygienic care recommended.