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Skin Assessment

Skin Assessment

amccallgru
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Skin Assessment

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  1. Skin & Lymph Assessment Amber McCall PhD, FNP-RN, RN This is the camera box for live lecture picture

  2. Objectives • Obtain skin and lymph medical history • Perform skin and lymph physical assessment • Recognize normalskin and lymph findings • On an adult patient • On a pediatric patient • Identify abnormalskin and lymph findings • On an adult patient • On a pediatric patient Smile, you’re on camera!

  3. Types of Data • Subjective • Objective • What patients say • What nurses Observe “I fell on the floor and my knee hurts bad, I think I cut it!” Hummm…My patient has a2 cm laceration on the left knee (which is an infection risk!). Smile, you’re on camera! Review

  4. Skin Smile, you’re on camera!

  5. What’s the largest organ of the human body? Smile, you’re on camera!

  6. “ “ The Great Protector Smile, you’re on camera!

  7. Important Note • During the head-to-toe exam, skin isn’t assessed separately, but completed while the nurse is assessing the other body systems • Regional exams are required for problem-specific skin issues (i.e., the patient’s chief complaint is a skin issue) Smile, you’re on camera! Inspection Palpation

  8. Get Your Gear Nurse’s eyes Nurse’s hands Ruler for skin measures Direct lighting Penlight Gloves Wood’s Light Magnifying Glass Smile, you’re on camera! Filtered UV light

  9. External Influences on Skin Color Emotions Environment Physical • Fear, anger • Embarrassment • Room temperature (too hot/cold) • Cigarette smoke • Prolonged elevation • Dependent position • Immobilization Be aware: External influences on skin can cause misleading outcomes Smile, you’re on camera!

  10. Subjective Data: Skin, Hair, Nails • Allergies, hives, psoriasis, eczema • Pigmentation color changes • Mole (size, color) changes (may indicate problem) • Excessive dryness (xerosis) • Excessive oil (seborrhea) • Pruritis (itching) • Excessive bruising • Hair loss (alopecia) • Excessive hair growth (hirsuitism) • Rash, lesions • Medication use (any recent changes) • Change in nails • Environmental, occupational hazards • Self-care (bathing, sunscreen, self skin evaluations, tanning beds) Smile, you’re on camera!

  11. Subjective Data: Skin, Hair, Nails Infants & Children Adolescents Acne “Pimples”, “blackheads” Tetracycline antibiotics Wear sunscreen (sun sensitivity) • Birthmarks • Physiologic jaundice (yellow, “bronze baby”) • Rashes • Burns, bruises (accident or abuse) • Exposure to contagious skin problems (scabies, impetigo, lice) • Habits (nail-biting) • Sun protection Smile, you’re on camera!

  12. Aging Adult Subjective Data: Skin, Hair, Nails • Any changes? • Xerosis (dry skin) • Delay in wound healing • Diabetes? • More at risk for infection (delayed wound healing) • Skin pain • Feet changes (bunions, etc.) • Frequent falls • Peripheral vascular disease Smile, you’re on camera!

  13. Objective Data: Skin Freckles Junctional nevus Compound nevus • Inspection, Palpation • Color • General pigmentation • Sun-exposed areas • Freckles (ephelides) • Moles (nevus) • Junctional (macular = flat, found in children & adolescents) • Compound (macular & papular = palpable) • Birthmarks flat raised Smile, you’re on camera! Consider the patient’s usual skin coloring

  14. Name that Abnormality Clue: Uneven skin tone (Absence of melanin) VS. Smile, you’re on camera! Even skin tone (no abnormality)

  15. Name that Abnormality Clue: Uneven skin tone (Absence of melanin) VS. Vitiligo Smile, you’re on camera! Even skin tone (no abnormality) Even skin tone (no abnormality)

  16. DANGER signs for pigmented lesions! Smile, you’re on camera! Variation Used with permission. Memory Notebook of Nursing, CD Images, Nursing Education Consultants, Inc. For student study purposes only, cannot be re-distributed by student in any means of communication (written, electronic, etc.).

  17. Objective Data: Skin • Inspection • Color: Widespread color change • Pallor (white) • Stress, fear (vasoconstriction) • Anemia • Observe mucous membranes, too • Cyanosis (blue) • Decreased perfusion • Hypoxemia, shock • Jaundice (yellow) •  bilirubin • Hepatitis, cirrhosis, sickle-cell • Erythema(red) • Fever (dilation of capillaries) • Polycythemia • Venous stasis • CO poisoning

  18. Quiz It! The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect? • Cyanosis • Flushing • Rubor • Jaundice Smile, you’re on camera!

  19. Quiz It! The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect? • Cyanosis • Flushing • Rubor • Jaundice Smile, you’re on camera!

  20. Objective Data: Skin • Inspection & palpation • Temperature • Hypothermia • Induced for fever, surgery • Occurs in shock, Raynaud’s disease (vasoconstriction of peripheral vessels) • Hyperthermia ( metabolic rate) • Trauma, infection, sunburn • Signs: warm, moist skin • Moisture • Diaphoresis (profuse perspiration) • Assess face, hands, axilla, skin folds • Dehydration • Assess mucous membranes • Dry, cracked, fissures < 95F < 35C > 101F > 38.3C Smile, you’re on camera! Dehydration

  21. Objective Data: Skin • Inspection & palpation • Texture • Smooth, firm, even? • Thickness • Epidermis (normally thin) • Calluses (hands, feet) • Edema • Present? • 1+ to 4+ pitting, meaning when you press deep down into the skin, a temporary indentation forms (if any pitting at all- not all swelling/ edema is pitting) When assessing pitting edema Sometimes you have to press deeply & firmly!!! Smile, you’re on camera!

  22. Objective Data: Skin • Inspection & palpation • Mobility & turgor • “Tent test” (assesses elasticity) • Pinch fold of skin • Good (returns to baseline) • Poor (remains tented) • Dehydration  turgor = dehydration Smile, you’re on camera!

  23. Objective Data: Skin I’m benign! • Inspection & palpation • Vascularity or bruising • Cherry angiomas (benign) • Contusion (bruise)? • Any tatoos? • Hepatitis C risk (needles) • Got lesions? • Note: • Color • Elevation [flat, raised, pedunculated (stalk-like)] • Pattern, shape (annular, grouped, linear) • Size (in cm), use ruler • Location on body, distribution (generalized, localized) • Exudative? Color, odor? Smile, you’re on camera!

  24. Wound Electronic Medical Record WEMR: HIPAA-compliant digital data sheet that contains the following data on a single screen. FYI only, no need to memorize steps (Rennert et al., 2009)

  25. Objective Data: Skin Wood’s light/ lamp is a filtered blacklight used to illuminate bacteria & fungi on the skin • Palpation • Lesions • Wear gloves for blood, mucosa, fluids, lesions • Scaly? • Depth? • Bleeds easily? • Blanchable? • Fluorescing lesions (use Wood’s light/lamp) • Fungal infections • Example: • Tinea capitis- ringworm of scalp Smile, you’re on camera!

  26. Skin Assessment: Overview of “Within Normal Limits” (WNL)

  27. Quiz It! Which of the following conditions would be “within normal limits” when palpating the skin of a patient? • The skin is cool & dry. • When picked up in a fold, the skin fold slowly returns to normal. • The skin is taut & moist to the touch. • The texture of the skin varies from smooth & soft to rough & dry. Smile, you’re on camera!

  28. Quiz It! Which of the following conditions would be “within normal limits” when palpating the skin of a patient? • The skin is cool & dry. • When picked up in a fold, the skin fold slowly returns to normal. • The skin is taut & moist to the touch. • The texture of the skin varies from smooth & soft to rough & dry. Should be warm & dry Should quickly return Smile, you’re on camera! Smile, you’re on camera! Taut = edema, Should be dry

  29. Objective Data: Hair • Inspect & palpate • Color • Melanin production • Texture • Thick, fine • Straight, curly, etc. • Distribution • Fine vs coarse • Locations on body • Hirsuitism (excessive body hair) • Lesions • Itching? • Seborrhea (dandruff) • Lice? Female with hirsuitism Smile, you’re on camera!

  30. Objective Data: Nails Clubbing is > 180 • Inspect & palpate • Shape & contour • Profile sign- normal angle nail & bed = 160 • Consistency • Smooth, brittle, splitting • Color & capillary refill (discussed in CV lecture) • Pink nail bed (fingers & toes) • Normal variations: • Linear pigmentation • Linear bands • Abnormal if sudden appearance in light-skinned people • Leukonychia striata • Trauma to cuticle Smile, you’re on camera!

  31. Teach Skin Self-care Exams It’s better to find a problem early vs. late. Screening = Secondary Prevention (discover the problem early before it worsens) Smile, you’re on camera! Teach patients: -Why self-assessment is important -To use mirrors -To look at all areas, both sun-exposed & not

  32. Developmental Care: Skin • Infants • Pigmentation • Mongolian spot • Looks like a bruise • Easily confused with child abuse • Rely on history • Café au lait spot • 6+ = neurofibomatosis risk • Assess for rash (a clue for neurofibromatosis) !

  33. Developmental Care: Skin • Infants • Color changes • Cutis marmorata (transient mottling due to blood vessel changes) • Physiologic jaundice (hemolyzed red blood cells) • Moisture • Vernix (natural, harmless cheese-like, white covering on baby after birth) !

  34. Developmental Care: Skin • Infants • Color changes • Birth- red flush (vasomotor instability) • Harlequin (color change, side lying position) • Erythema toxicum (rash, first 3-4 days of life) • Acrocyanosis(blue extremities, usually temporary) ! Caused by immune system activation response

  35. Developmental Care: Skin • Infants • Texture • Milia (white papules) • Thickness • Subcutaneous fat • Mobility, turgor • Tenting = dehydration • Vascularity, bruising • Storkbite(aka salmon patch) !

  36. Developmental Care: Hair, Nails • Infants • Hair • Lanugo (fine hair) • Nails • Cyanotic at birth • Pink soon after !

  37. Gaa … Mamma! (or Daddy!)– What’s up with my skin?! It’s Game Time Goo…

  38. Mamma (Daddy)—What’s Up With My Skin? !

  39. Mamma (Daddy)—What’s Up With My Skin? Stork bite (temporary) Lanugo (fine hair) !

  40. Mamma (Daddy)—What’s Up With My Skin? !

  41. Mamma (Daddy)—What’s Up With My Skin? Erythema toxicum (temporary rash, no treatment needed) ! Mongolion Spot Mongolion Spot (eventually fades)

  42. Mamma (Daddy)—What’s Up With My Skin? !

  43. Mamma (Daddy)—What’s Up With My Skin? Cutis marmorata (mottling, due to vessel constriction, temporary) ! Café au lait spot Café au lait spot (doesn’t fade, if 6 or more, assess for neurofibromatosis, look for rash)

  44. Mamma (Daddy)—What’s Up With My Skin? !

  45. Mamma (Daddy)—What’s Up With My Skin? Physiologic jaundice (yellowing of skin, slcera & mucous membranes due to  numbers of RBCs hemolyzed , split open, following birth) ! Carotenemia (yellow-orange color in light-skinned persons from large amounts of foods containing carotene, like carrots)

  46. Developmental Care: Skin • Adolescents • Acne •  sebaceous glands Comedones(aka blackheads) Severe Acne (has pustules) !

  47. Developmental Care: Skin Pregnant Women • Stretch marks (striae) • Linea nigra • Vascular spiders • Chloasma (mask of pregnancy) Smile, you’re on camera!

  48. Developmental Care: Skin • Aging adult • Skin color & pigmentation • Senile lentigines/lentigo • “Liver spots” • Seborrheic keratoses • Thickened, scaly lesions • Actinic keratosis • Scaly plaques !

  49. Developmental Care: Skin • Aging adult • Moisture • Xerosis (dry skin) • Texture • Acrochordons • “skin tags” • Location: eyelids, cheeks, neck, axillae, trunk !

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