Skin 1
ALLENTOWN COLLEGE OF ST. FRANCIS DE SALES
DEPARTMENT OF NURSING AND HEALTH
Nursing 201
Nursing Skills Laboratory Procedure: Assessment of the Skin
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ACTION
Inspect the skin for general pigmentation, by observing the general pigmentation
of the client’s skin from all angles
Inspect the skin for general color, by observing the general color of the client’s
skin from all angles
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Palpate the skin for temperature, by 1) placing the dorsal (back) surface of your
fingers and hands bilaterally against all areas of the client’s skin, and 2) moving
the dorsal (back) surface of your fingers and hands bilaterally over all areas of the
client’s skin
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Palpate the skin for moisture
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NORMAL FINDINGS
Symmetry
Uniform pigmentation
Areas of lighter
pigmentation on the
palms, nail beds, lips,
and soles of the feet
(in dark-skinned
people)
Symmetry
Uniform color
Skin color consistent
with genetic
background
Exposed areas of the
body (face, ears, back
of the neck, backs of
the hands and arms)
are noticeably different
from unexposed areas
Symmetry
Generalized warmth
Symmetry
Uniform moisture
Increased moisture in
the face, soles of the
ABNORMAL FINDINGS
 Asymmetry
 Ephelides (freckles)
 Nevus (mole)
 Birthmark
 Vitiligo
 Albinism
 Cholasma
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Asymmetry
Pallor
Erythema
Cyanosis
Jaundice
Brown-Tan (bronze)
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Asymmetry
Generalized hotness
Generalized coolness
Localized areas of
hotness or coolness
Asymmetry
Dry
Oily
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Skin 2
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Palpate the skin for texture
Palpate the skin for thickness
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Palpate the skin for pitting edema of the right foot, ankle, and leg, by 1) having
the client lie down on an examining table, 2) pressing the thumb of your right
hand firmly for 5 seconds over the dorsum of the client’s right foot, behind the
medial malleolus of the client’s right ankle, and over the client’s right shin, 3)
removing the thumb of your right hand from over the dorsum of the client’s right
foot, behind the medial malleolus of the client’s right ankle, and over the client’s
right shin, and 4) observing for an indentation left in the skin over the dorsum of
the client’s right foot, behind the medial malleous of the client’s right ankle, and
over the client’s right shin (Reverse to test for pitting edema of the left foot,
ankle, and leg)
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feet, palms of the
hands, and
intertriginous areas
(where two surfaces
are close together) in
response to activity,
warm environment, or
anxiety
Symmetry
Uniform texture
Skin texture smooth,
firm, with an even
surface
Symmetry
Skin thin and firm
Thickened areas on
the palms, soles of the
feet, elbows, and
knees
Callused areas on the
palms and soles of the
feet
Absence of edema
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Asymmetry
Skin texture
excessively smooth,
soft, and velvety
(hyperthyroidism)
Skin texture
excessively rough, dry,
or scaly
(hypothyroidism)
Asymmetry
Skin very thin, shiny
(atrophic)
Mild (1+), moderate
(2+), deep (3+), very
deep (4+) pitting
edema
Anasarca
Skin 3
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Palpate the skin for mobility and turgor, by 1) pinching up a large fold of skin on
the anterior chest under the client’s right or left clavicle, 2) releasing the pinched
fold of skin on the anterior chest under the client’s right or left clavicle, and 3)
observing the movement of the pinched fold of skin under the client’s right of left
clavicle after it is released
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Inspect the skin for hygiene, by observing the client’s skin from all angles
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Inspect the skin for primary, secondary, vascular and purpuric, and miscellaneous
lesions, noting their color, elevation, pattern or shape, size, location and
distribution, and presence of exudate, by observing the client’s skin from all
angles
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Pinched skin returns
immediately to its
previous shape and
position
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Symmetry
Clean
Absence of body odor
Absence of skin
lesions
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Pinched skin returns
to its previous shape
and position  5
seconds
Pinched skin remains
in a pinched state
Asymmetry
Unclean
Presence of body odor
Macule
Patch
Papule
Plaque
Nodule
Tumor
Wheal
Vesicle
Bulla
Pustule
Erosion
Ulcer
Fissure
Crust
Scale
Cherry angioma
Spider angioma
Venous star
Petechiae
Purpura
Ecchymosis
Lichenification
Atrophy
Excoriation
Scar
Keloid
Skin 4
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Comedo
Telangiectasia
Nevus (mole)
TYPES OF PIGMENTATION CHANGES
PIGMENTATION CHANGE
Freckles (ephelides)
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Nevus (mole)
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Birthmark
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Vitiligo
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Albinism
Cholasma
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DESCRIPTION
Pigmentation change evidenced by a small, flat macules of brown melanin pigment
occurring on sun-exposed skin
Pigmentation change evidenced by a flat or raised even proliferation of melanocytes, tan to
brown in color
Pigmentation change evidenced by a patchy, flat proliferation of melanocytes, tan to brown
in color
Pigmentation change evidenced by a patchy, complete absence of melanin pigment on the
face, neck, hands, feet, body folds, and around body orifices
Pigmentation change evidenced by a generalized, complete loss of melanin pigment
Pigmentation change evidenced by a patchy, flat proliferation of melanocytes on the
forehead adjacent to the hairline, malular prominence, upper lip, and chin; also known as
the “mask of pregnancy”
TYPES OF SKIN LESIONS
LESION
Macule
Patch
Papule
Plaque
Nodule
Tumor
Wheal
PRIMARY SKIN LESIONS (MAY ARISE FROM PREVIOUSLY NORMAL SKIN)
DESCRIPTION
 Skin lesion evidenced by a circumscribed, flat, nonpalpable change in skin color that is  1
centimeter
 Skin lesion evidenced by a circumscribed, flat, nonpalpable change in skin color that is  1
centimeter
 Skin lesion evidenced by a palpable, elevated, solid mass that is  0.5 centimeters
 Skin lesion evidenced by a palpable, elevated, solid mass that is  0.5 centimeters
 Skin lesion evidenced by a palpable, elevated, solid mass that is 0.5-2 centimeters and
firmer than a papule
 Skin lesion evidenced by a palpable, elevated, solid mass that is  2 centimeters
 Skin lesion evidenced by a palpable, elevated, solid mass that is irregular, with a superficial
Skin 5
area of skin edema
Skin lesion evidenced by a circumscribed, superficial elevation of the skin formed by free
fluid (serous) in a cavity within the skin layers that is  0.5 centimeters
Bulla
 Skin lesion evidenced by a circumscribed, superficial elevation of the skin formed by free
fluid (serous) in a cavity within the skin layers that is  0.5 centimeters
Pustule
 Skin lesion evidenced by a circumscribed, superficial elevation of the skin formed by free
fluid (pus) in a cavity within the skin layers that is  0.5 centimeters
SECONDARY SKIN LESIONS (RESULT FROM CHANGES IN PRIMARY LESIONS)
LESION
DESCRIPTION
Erosion
 Skin lesion below the skin plane evidenced by a loss of epidermis resulting in a moist,
nonbleeding surface
Ulcer
 Skin lesion below the skin plane evidenced by a loss of epidermis and dermis which may
result in a scarred, bleeding surface
Fissure
 Skin lesion below the skin plane evidenced by a linear crack that extends from the
epidermis to the dermis
Crust
 Skin lesion evidenced by material on the skin surface: dried residue of serum, pus, or blood
Scale
 Skin lesion evidenced by material on the skin surface: heaped-up, keratinized cells;
exfoliated epidermis
VASCULAR AND PURPURIC SKIN LESIONS
LESION
DESCRIPTION
Cherry (senile) angioma
 Skin lesion evidenced by a change in skin pigmentation whose shape is round and is flat or
elevated, ruby red in color and is 1-3 centimeters
Spider angioma
 Skin lesion evidenced by a change is skin pigmentation whose shape is spider-like, with a
central body with radiating legs, and is flat or elevated, fiery red in color, does not blanch
with pressure over the central body, and is very small to 2 centimeters
Venous star
 Skin lesion evidenced by a change in skin pigmentation whose shape is spider-like, with a
central body with radiating legs, or linear, irregular, or cascading, and is flat, bluish in color,
does not blanch with pressure, and is variable is size
Petechiae
 Skin lesion evidenced by a change in skin pigmentation whose shape is irregular and is flat,
reddish-purple in color, does not blanch with pressure, and is  0.5 centimeters
Purpura
 Skin lesion evidenced by a change is skin pigmentation whose shape is irregular and is flat,
reddish-purple in color, does not blanch with pressure, and is  0.5 centimeters
Ecchymosis
 Skin lesion evidenced by a change is skin pigmentation whose shape is irregular and is flat,
reddish-purple, does not blanch with pressure, and is variable in size, but usually  3
Vesicle
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Skin 6
LESION
Lichenification
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Atrophy
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Excoriation
Scar
Keloid
Comedo
Telangiectasisa
Nevus (Mole)
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millimeters
MISCELLANEOUS SKIN LESIONS
DESCRIPTION
Skin lesion evidenced by a thickening and roughening of the epidermis, with increased
visibility of the skin furrows
Skin lesion evidenced by a thinning of the skin, with decreased visibility of the skin furrows
and a shiny appearance
Skin lesion evidenced by a superficial, linear scratch of the epidermis
Skin lesion evidenced by a replacement of destroyed dermis by fibrous tissue
Skin lesion evidenced by a hypertrophied scar
Skin lesion evidenced by plugged opening of a sebaceous gland; a hallmark of acne
Skin lesion evidenced by a surface network of fine, irregular dilated blood vessels
Skin lesion evidenced by a flat or raised even proliferation of melanocytes, tan to brown in
color
CONFIGURATION OF SKIN LESIONS
CONFIGURATION
Annular
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Confluent
Discrete
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Grouped
Gyrate
Iris
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Linear
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Polycyclic
Zosteriform
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DESCRIPTION
Configuration of skin lesions in which the skin lesions begin in the center and spread to the
periphery resembling a ring
Configuration of skin lesions in which the skin lesions run together
Configuration of skin lesions in which the individual skin lesions are distinct and remain
separate
Configuration of skin lesions in which the skin lesions are clustered
Configuration of skin lesions in which the skin lesions are twisted, coiled, spiral, snakelike
Configuration of skin lesions in which the skin lesions are concentric rings resembling the
iris of the eye
Configuration of skin lesions in which the skin lesions resemble a scratch, streak, line, or
stripe
Configuration of skin lesions in which annular skin lesions grow together
Configuration of skins lesions in which the skin lesions form a linear arrangement along a
nerve route
Skin 7
GRADING PITTING EDEMA
GRADE
1+
2+
3+
4+
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DESCRIPTION
Mild; 2 millimeter indentation, no perceptible swelling of the leg
Moderate; 4 millimeter indentation that subsides rapidly
Deep; 6 millimeter indentation that remains for a short time; leg looks swollen
Very deep; 8 millimeter indentation that lasts for a long time; leg looks swollen