– It consist the skin, nails and scalp.
– Provides the body’s external protection and regulates body temperature.
– It acts as a sensory organ for pain, temperature and touch.
- Window to detect a variety of conditions affecting the client.
- It views the changes in oxygenation, circulation, nutrition, local tissue damage and hydration.
– Ask the patient about any presence of lesions, rashes and bruises.
– Determine whether there has been a recent change in skin color or trauma in the skin.
– Assess for history of allergies, use of topical medications and a family history of serious skin disorder.
– Skin color should be uniform all over the body.
– Normal skin pigmentation ranges from ivory or light pink to ruddy pink in white skin and light to deep brown or olive in dark skin.
– Check for any signs of alterations in skin color.
– Hydration of skin and mucous membranes helps to reveal body fluid imbalances, changes in the skin’s environment and regulation of body temperature.
– Refers to the wellness and oiliness of the skin.
– Depends on the amount of blood circulating through the dermis.
– Increase or decrease in skin temperature reflects on increase or decrease in blood flow.
– More accurately assessed by palpating the skin with the dorsum of the hand.
– It is the character of the skin’s surface and the feel of deeper sensation.
– Normally smooth, soft and flexible.
– It is the skin’s elasticity which can be diminished by edema or dehydration.
– Normally looses its elasticity with age.
– The hand or forearm is grasped with the fingertips and is released.
– The nurse inspects edematous areas for location, color and shape.
– Edematous skin also appears stretched and shiny.
– Palpate area of edema to determine mobility, consistency and tenderness.
Edema is usually caused by direct trauma and or impairment of venous return. Failure of the skin to reassume its normal contour or shape after being pinched indicated dehydration which places the patient at risk for skin breakdown. Tenting is the term to describe skin that remains in a pinched position.
Procedure: Palpate dependent areas (sacrum, feet, and ankles) for mobility by applying pressure with fingers noting degree of indentation. If indentation occurs, firmly apply pressure with your thumb for 5 seconds. Note the degree of edema based on the depth of indentation (pitting) in centimeters. Dependent edema gives the skin a stretched, shiny appearance. The degree of pitting edema reflects the depth if indentation (1+ to 5+).
– Skin is normally free of lesions.
– When a lesion is detected, inspect for color, location size, type and distribution.
– Palpation determines the lesion’s mobility, contour and consistency.
Types of skin lesions:
- Macules – freckles and petichiae
- Papules – small moles, acne
- Nodules – big mole
- Tumor – extends to the subcutaneous area
- Wheal – superficial, localized edema (e.g. mosquito bites)
- Vesicle – chicken pox
- Pustule – with pus (e.g. acne vulgaris)
- Ulcer – deep loss of skin
- Atrophy – thinning of skin (e.g. arterial insufficiency)
- Hair and Scalp
Types of hair:
- Terminal hair – long
- Vellus hair – tiny hair
– Changes in growth or loss of hair.
– Types of hair care products used.
– Has the patient undergone chemotherapy?
– Inspect distribution, texture and lubrication of body hair.
– Observe characteristics of color and coarseness.
– Inspect the scalp for lesions and presence of lice.
Alopecia (hair loss) is one effect of chemotherapy and some patients may be having hirsutism (excessive hair growth). Dry flaking, scaling occurs in seborrhea (dandruff) and psoriasis (red patches covered by thick, silvery, adherent scales that result form excessive development of epithelial cells.
– Ask for history of any trauma.
– Ask the patient to describe nail care practices.
– Inquire whether the patient has risks for nail-foot problems.
Inspection and Palpation:
– Inspect the nail bed color, thickness and shape of the nail.
– Palpate the nail base to determine firmness and condition of circulation.
– Assess for capillary refill by using blanching test.