The Patient’s Skin Assessment should be part of the routine head-to-toe assessment of all patients. A skin assessment should include an actual observation of the entire body. It differs from a wound assessment in that it looks at the patient’s entire body, not just open wounds.
1. Temperature assessment:
- Normally warm to the touch
- Warmer than normal could signal inflammation
- Cooler than normal could signal poor vascularization
2. Color assessment:
- Intensity: paleness may be an indicator of poor circulation
- Normal color tones: light ivory to deep brown, yellow to olive, or light pink to dark, ruddy pink
- Hyperpigmentation or hypopigmentation reflect variations in melanin deposits or blood flow.
3. Moisture assessment:
- Dry or moist to touch
- Hyperkeratosis (flaking, scales)
- Eczema (endogenous or exogenous)
- Dermatitis, psoriasis, rashes
- Edema
4. Turgor assessment:
Normally returns to its original state quickly Slow return to its original shape (dehydration or effect of aging)
5. Integrity assessment;
- No open areas
- Type of skin injury (Use the appropriate classification system to identify and record injury type)
Elements of a comprehensive skin assessment
1-Inspection
- Normally smooth, slightly moist, and same general tone throughout
- Tone depends on patient’s melanocytes
- Pigmentation can exhibit:
- pallor: mucosa, conjunctivae
- cyanosis: nail beds, conjunctivae, oral mucosa
- jaundice: sclera, palate, palms
- Hyperpigmentation: increased (Results from variation in melanin deposits or blood flow; palpate for skin temperature and for edema over these areas to assess circulation.)
- hypopigmentation: decreased vascular/venous patterns, usually symmetric
- scars and bruises for location, color, length, and width
2-Palpation
- Moisture: perspiration
- Edema: extremities, sacrum, eyes
- Tenderness
- Turgor, elasticity
- Texture
3-Olfaction
- May indicate presence of bacteria or infection
- Poor hygiene
- Normal body odor
- Absence of pungent odor
4-Observation of hair and nails
- Hair (• excessive body hair • Alopecia: hair loss )
- Nails (can reflect the patient’s overall health) • Color, shape, contour • Clubbing, texture, thickness
5-Skin alterations
- Previous scars
- Graft sites
- Healed ulcer sites