Health history questions for skin
Change in pigmentation?
Change in mole?
Excessive dryness or moisture?
Pruritus
Excessive bruising
Rash or lesion
Medications
Hair loss
Change in nails
Environmental or occupational hazards
self-care behaviors
Physical exam of the skin
Inspect and palpate. What is the color of the skin? Is there general pigmentation? Any widespread color change? observe the temperature, moisture, and texture
Skin color/tone
Assess areas not exposed to the sun
Assess for even pigmentation
Consistent with genetic background
Skin variations
Varies from:
pinkish tan to ruddy dark tan
light to dark brown
May have yellow or olive overtones
Normal skin tones: pink, tan, brown, black
Dark skinned people
normally have areas of lighter pigmentation on palms, nail beds and lips
reliable sites to assess color changes in dark skinned people
under the tongue
buccal mucosa
conjunctivae
Sclera
Cyanosis
Mottled blue color in skin. The amount of unoxygenated hemoglobin causes inadequate tissue perfusion.
Cyanosis in light skin
Skin, lips, and mucous membranes look blue tinged.
Conjunctivae and nail beds are blue
Cyanosis in dark skin
Skin may be a shade darker. May be undetectable except for lips, tongue, oral mucous membranes, nail beds or conjunctivae
Pallor
Loss of color due to absence of oxygenated Hbg
Pallor in light skin
Loses rosy tones
Pallor in skin with natural yellow tones
appears more yellow (may be mistaken for jaundice)
Pallor in dark skin
Loses healthy glow
Pallor in black skin
Loses red undertones, appears ash-gray and dull
Pallor in brown skin
Appears yellow brown, dull
Jaundice
Yellow undertone due to bilirubin in the blood
Jaundice in light skin
Yellow
visible in sclera, oral mucosa, hard palate, fingernails, palms of hands and feet
Jaundice in dark skin
Visible in sclera, oral mucosa, junction of hard and soft palate, palms of hands and soles of feet.
Erythema
redness
light skin: red, bright pink
Dark skin: purplish tinge (difficult to see)
assessing erythema
Palpate for warmth with inflammation, taut skin, hardening of deep tissues
Skin temperature
Normal=warm
Depends on the peripheral vascular circulation to the skin, cardiovascular status
Normally uniform over the body with variances in limbs
To assess, use the dorsal aspects of the hands
Skin moisture
Normally dry with moisture in axilla, skin folds and in response to activity or anxiety, emotional state
Turgor
Elasticity.
Indicator of total body hydration
To assess: Use forefinger and thumb; lift and pinch fold of skin on extremity (beneath clavicle or on radial aspect of wrist)
Elderly: pinch-fold test for hydration
Abnormal: tenting-when skin remains pinched,
Edema
Fluid that accumulates in intercellular spaces; excess fluid and is not normally present
occurs in dependent parts of the body such as feet, ankles and sacral areas
Looks puffy and tight
To assess: location, whether the area remains indented (or pitted) w
Edema scale
1+ barely detectable; slight indentation (2mm)
2+ indentation of less than 5mm
3+ indentation of 5-10 mm--puffy, deeper pitting
4+ indentation of more than 10 mm
Skin texture
should be smooth, soft
grows more coarse with age
Skin lesions
Pathological change in the structure of the skin
Assessment of lesions
Color
Elevation: flat, raised
Pattern or shape
Border
Size: in centimeters (cm vs. inches)
Location and distribution on the body
Exudate: COCA
Types of lesions
Primary and secondary skin lesions
Primary lesion
A lesion that is a physical alteration of the skin and considered to be directly caused by the disease process which is characteristic and occasionally specific.
Secondary lesion
A lesion that change over time or as a result of scratching, trauma, infection, or changes caused by healing.
Flat primary lesion
Circumscribed, flat nonpalpable changes in skin color; well defined; definite boundaries or limits.
Macule
Flat, discolored lesion with no elevation.
< 1 cm in size.
Patch
Flat, nonpalpable, irregular.
> than 1 cm
Macule/patch color
1) melanin pigmentation in the epidermis
2) blue, due to melanin or other particulates (such as tatto pigments) in the dermis
3) Red, due to vasodilation in the dermis with or without inflammatory cells present.
Raised primary lesions
Palpable, elevated solid masses
Papule
Elevated pinpoint lesion: < than 1 cm
Plaque
Groups of papules; > than 1 cm and do not extend into lower skin layers
Nodule
Elevated, solid, hard or soft palpable mass extending deeper into the dermis than a papule; 1-2 cm in diameter
Tumor
> than 2 cm in diameter; solid mass larger than nodule
Wheal
Elevated transient with a variable diameter
superficial localized skin edema
Fluid-filled primary lesions
Circumscribed, superficial elevations of the skin formed by free fluid in a cavity within the skin layers
Types of primary lesions with fluid
Vesicle
Bulla
Pustule
Cyst
Types of secondary lesions
Scales
Crusts
Excoriation
Fissures
Ulcers
Scar
Atrophy
Striae
Lichenification
Scales
Flakes of dead epidermis; epidermal thickening
Crusts
Covering formed from serum, blood or pus drying on the skin; dried serum
Excoriation
Injury to the surface of the skin due to trauma, such as scratching or abrasion.
Fissures
Linear cracks with sharp eduges extending into the dermis. Cracked or split.
Ulcers
Lesion formed by the loss of the epidermis and etending into deeper tissues. Results in the loss of epidermis and dermis.
Scar
Area of connective tissue left after a lesion or wound is healed. Thickening, fibrous tissue.
Atrophy
Translucent, dry, paperlike, sometimes wrinkled skin surface as a result of thinning or wasting of skin due to collagen and elastic; loss of substance.
Striae
Long line, appearing like scars due to stretching of the subcutaneous tissue.
Lichenification
Thickening with a skin line accentuation.