SKIN

• Assessment of the skin includes inspection, palpation, and in some instances, the nurse may need to use olfactory sense to detect unusual skin odors
• Dermis


  • Middle region (bulk of skin); responsible for most of the structural strength of the skin, leather is produced from the dermis of animals
• Skin Color

  • Melanocytes produce melanin inside melanosomes and transfer it to keratinocytes, size and distribution of melanosomes determine skin color, melanin production is genetically determined but can be influenced by UV light and hormones
• 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
• Major regions of the skin

  • Epidermis
  • Dermis
  • Subcutaneous tissue (hypodermis)
• Equipment for skin examination

  • Good lighting
  • Disposable gloves
  • Metric ruler
  • Mirror
  • Penlight
  • Examination gown or drape
• 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 surface area is 1.2-2.2 m2 and weighs 4-5 kg (9-11 lbs)
• Epidermis


  • Outermost region (superficial); resists abrasion, reduces water loss, composed of epithelial tissue
• Skin breakdown is initially noted as a reddened area in the skin that may progress to serious and painful pressure ulcers
• Assessment Procedure


  Inspect for color variations in localized parts of the body noting any color variations
• Dry, itchy skin is a common concern in obese clients
• Bruises, welts, or burns may indicate accidents, trauma, or abuse
• Inspect for lesions


  Observe the skin surface to detect abnormalities. Note color, shape, and size of lesion
• Albinism


  The complete or partial lack of melanin in the skin, hair, and nails
• Some clients may have suntanned areas, freckles, or white patches known as vitiligo due to different amounts of melanin in certain areas
• If unexplained injuries or vague explanations are given, physical abuse should be suspected
• Birthmarks, tattoos, or moles changing color, size, or shape may indicate cancer
• Rashes, lesions, dryness, oiliness, drainage, bruising, swelling, or increased pigmentation are symptoms related to a pathological skin condition
• Check skin integrity


  Especially the pressure points (sacrum, hips, elbows)
• Lesions may indicate local or systemic infection problems
• Abnormal findings for skin inspection

  • Lesions may indicate local or systemic infection problems
• Normal findings for skin inspection

  • Skin is normal, no reddened areas
• Normal findings for skin texture palpation


  • Smooth, without lesions. Stretch marks, healed scars, freckles, moles, or birthmarks are common findings
• Abnormal findings for skin moisture palpation

  • Increased moisture or diaphoresis may occur in conditions such as fever. Decreased moisture occurs with dehydration
• Abnormal findings for skin temperature palpation

  • Cold skin may accompany shock or hypotension
• Assessment for pressure ulcers

  1. Inspect skin for lesions

  2. Observe skin surface to detect abnormalities

  3. Palpate skin to assess texture

  4. Palpate to assess moisture

  5. Palpate to assess temperature

  6. Palpate to assess mobility

  7. Palpate to detect edema
• Normal findings for skin edema detection


  • Skin rebounds and does not remain indented when pressure is released
• Normal findings for skin moisture palpation

  • Skin surfaces vary from moist to dry depending on the area assessed. Recent activity or a warm environment may cause increased pressure. Hyperhidrosis – excessive perspiration. Bromhidrosis – foul-smelling perspiration
• Normal findings for skin mobility assessment

  • Skin goes back to its original state after 2 seconds
• Edema is the presence of excess interstitial fluid. An area of edema appears swollen, shiny, and taut and tends to blanch the skin color. It is often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or vein abnormalities
• Abnormal findings for skin edema detection

  • Indentations on the skin may vary slight to great and may be in one area or all over the body
• Abnormal findings for skin mobility assessment

  • Decreased mobility seen with edema. Decreased turgor (a slow return of the skin to its normal state taking longer than 3 seconds) seen in dehydration
• Normal findings for skin temperature palpation

  • Skin is normally warm in temperature
• Epidermis

  • Resists abrasion
  • Reduces water loss
  • Composed of epithelial tissue
• Assessment of the skin

  1. Includes inspection, palpation, and in some instances, the nurse may need to use olfactory sense to detect unusual skin odors

  2. PUNGENT BODY ODOR is usually related to poor hygiene
• Subcutaneous tissue (hypodermis)


  • 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
• Regions of the skin

  • Epidermis: outermost region (superficial); Dermis: middle region (bulk of skin); Subcutaneous tissue (hypodermis): deepest region
• Dermis

  • Responsible for most of the structural strength of the skin
  • Leather is produced from the dermis of animals
• Skin Color

  • Melanocytes produce melanin inside melanosomes and transfer it to keratinocytes
  • Melanin production is determined genetically but can be influenced by UV light and hormones