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02-28-2013, 11:50 AM
assessment of skin
NURSING ASSESSMENT
Health History
Skin problems are a fairly common complaint for the patient
entering the health system. Many factors can influence
the integumentary system. A skin problem may be the
only complaint the patient has, or it may be a manifestation
of an underlying systemic condition or psychological stress.
Most important, the skin visibly communicates the patient’s
health. Therefore the questions that are posed to the
patient are important in determining if the skin problem is
a disease entity of its own or a sign of a more systemic disorder.
Table 50–1 provides examples of general questions
that can be asked of the patient to elicit information.
If further assessment of a particular problem area is necessary,
the WHAT’S UP? line of questioning may be used.
For example, if the patient has a rash, you can respond with
the following questions:
Where is it? Is that the only area where you have a rash?
How does it feel? Does it itch? Burn?
Aggravating and alleviating factors. Does scratching aggravate
it? Does anything else aggravate it, such as soaps and
detergents? What relieves it? How have you treated it in
the past?
Timing. How long have you had this problem? Does it recur?
Severity. How bad is the discomfort on a scale of 0 to 10, with
0 being comfortable and 10 being unable to touch the
area?
Useful other data. Do you have other symptoms besides the
rash, such as itching, discharge, tingling, or loss of sensation?
Patient’s perception. What do you think is causing your rash?
Physical Assessment
Assessment of the skin involves **t only the entire skin area,
but also the hair, nails, scalp, and mucous membranes. The
main techniques utilized in physical assessment of the skin
are inspection and palpation. Ensure that the patient is disrobed
but adequately draped in a well-lighted and warm environment.
A handheld magnifying glass or penlight may be
utilized to see small details and further illuminate the area.
**rmally the skin is intact, with ** abrasions, and is
smooth, dry, well hydrated, and warm. Skin turgor is firm andelastic. The skin surface is flexible and soft. Skin color ranges
from light to ruddy pink or olive in white-skinned patients
and light brown to deep brown in dark-skinned patients.
You need to be aware of **rmal developmental changes
when performing an assessment. The skin of the neonate is
very thin and friable (easily broken). During adolescence,
the skin becomes thicker, with active sebaceous, eccrine,
and apocrine glands. Body hair also changes during adolescence
as a result of hormonal influences. In older patients
the skin loses some of its elasticity and moisture. There is
decreased activity of sebaceous and sweat glands. The older
patient’s skin is thinner, more fragile, and more wrinkled.Inspection
Inspect each area of the skin, including nails, hair, scalp,
and mucous membranes, for color, moisture, lesions, edema,
intactness, vascular markings, turgor, and cleanliness. This
examination should be done in an orderly sequence, such as
hair, scalp, nails, buccal mucosa, and then the general skin
surface from head to toe (Gerontological Issues Box 50–1).
COLOR. Skin color can be influenced by many factors, including
the temperature of the patient, oxygenation, blood
NURSING ASSESSMENT
Health History
Skin problems are a fairly common complaint for the patient
entering the health system. Many factors can influence
the integumentary system. A skin problem may be the
only complaint the patient has, or it may be a manifestation
of an underlying systemic condition or psychological stress.
Most important, the skin visibly communicates the patient’s
health. Therefore the questions that are posed to the
patient are important in determining if the skin problem is
a disease entity of its own or a sign of a more systemic disorder.
Table 50–1 provides examples of general questions
that can be asked of the patient to elicit information.
If further assessment of a particular problem area is necessary,
the WHAT’S UP? line of questioning may be used.
For example, if the patient has a rash, you can respond with
the following questions:
Where is it? Is that the only area where you have a rash?
How does it feel? Does it itch? Burn?
Aggravating and alleviating factors. Does scratching aggravate
it? Does anything else aggravate it, such as soaps and
detergents? What relieves it? How have you treated it in
the past?
Timing. How long have you had this problem? Does it recur?
Severity. How bad is the discomfort on a scale of 0 to 10, with
0 being comfortable and 10 being unable to touch the
area?
Useful other data. Do you have other symptoms besides the
rash, such as itching, discharge, tingling, or loss of sensation?
Patient’s perception. What do you think is causing your rash?
Physical Assessment
Assessment of the skin involves **t only the entire skin area,
but also the hair, nails, scalp, and mucous membranes. The
main techniques utilized in physical assessment of the skin
are inspection and palpation. Ensure that the patient is disrobed
but adequately draped in a well-lighted and warm environment.
A handheld magnifying glass or penlight may be
utilized to see small details and further illuminate the area.
**rmally the skin is intact, with ** abrasions, and is
smooth, dry, well hydrated, and warm. Skin turgor is firm andelastic. The skin surface is flexible and soft. Skin color ranges
from light to ruddy pink or olive in white-skinned patients
and light brown to deep brown in dark-skinned patients.
You need to be aware of **rmal developmental changes
when performing an assessment. The skin of the neonate is
very thin and friable (easily broken). During adolescence,
the skin becomes thicker, with active sebaceous, eccrine,
and apocrine glands. Body hair also changes during adolescence
as a result of hormonal influences. In older patients
the skin loses some of its elasticity and moisture. There is
decreased activity of sebaceous and sweat glands. The older
patient’s skin is thinner, more fragile, and more wrinkled.Inspection
Inspect each area of the skin, including nails, hair, scalp,
and mucous membranes, for color, moisture, lesions, edema,
intactness, vascular markings, turgor, and cleanliness. This
examination should be done in an orderly sequence, such as
hair, scalp, nails, buccal mucosa, and then the general skin
surface from head to toe (Gerontological Issues Box 50–1).
COLOR. Skin color can be influenced by many factors, including
the temperature of the patient, oxygenation, blood