Skin Assessment

Question 1

What are all the parts of Skin Assessment?

Answer 1

Normal Skin Characteristics
Lesions
ABCDE
Pitting Edema
Skin changes d/t aging

Question 2

Normal Skin Characteristics

Answer 2

TTTOMCL

o Texture – is the smooth & soft, flaky, and dry, rough or course, thin or shiny,
breaks easily or light.

o Temperature – warm/cool; upper and lower extremities, left and right

o Turgor – gently pinch the skin.
DEHYDRATION – skin takes several seconds to
return to normal position (aka tenting). INCREASED TURGOR – skin tight
(edema or scleroderma)

o Odor – no unusual odors. Poor hygiene, wounds, urine, or stool – unpleasant
body odors

o Moisture – Is the skin dry or moist, any cracked, flakiness, mucous membranes
(mouth gums eyes and tongue) moist or dry. Any sweating - environment

o Color – same color all over, may vary r/t age, race. Is the skin color pale, cyanotic(blue), yellow(jaundice)

o Lesions – if present – Assess, identify, measure, and describe

Question 3

Lesions

Answer 3

o Lesions – if present – Assess, identify, measure, and describe –

> Lentigo Senilis: Liver Spots, light brown macules from Lots of Sun exposure, likely benign

> Seborrheic keratosis – Superficial, safe (benign); brown, roung, rough

> Senile purpura – d/t Skin thinning, sensitive blood vessels, like purple bruises

> Skin Tags (Acrochordons) – Small tags, skinfolds, snags on neck/underarm

Elderly person in the sun
- Lentigo: Lotion on skin
- Seborrheic Keratosis: Raised patches
- Senile Purpura: Bruise from bumping
- Shirt collar: Skin tag

Question 4

ABCDE for melanomas/risk of skin cancer

Answer 4

Asymmetry: not the same, one half unlike the other
Border: irregular
Color: uneven + brown, tan, or black
Diameter: usually larger that 6 mm but can be smaller
Evolution: looks diff than others or changing in size etc.

Question 5

Pitting Edema

Answer 5

Press fingertips for 5 seconds over a bony area, remove and observe

If edema note location, degree and type of swelling.
- +1 2mm rapid return of skin position
- +2 4mm returns in 10 – 15 seconds
- +3 6mm returns in 1 -2 minutes – (swollen)
- +4 8mm returns in 2 -3 mins (gross edema)

Question 6

Skin changes associated with aging

Answer 6

1. DRY: d/t decreased sebum (oil) production.
2. DECREASE SWEATING: d/t decreased functioning of sweat gland.
3. SKIN THING & EASILY TEARS: d/t thinning epidermis.
4. WRINKLES, SAGGING: d/t loss of subcutaneous fat, water, and elastic fiber.
5. DECREASED SKIN TURGORr: d/t loss of elastic fibers/deceased fluid intake
6. PROMINENT VEINS
7. DIMINISHED PAIN PERCEPTION

Question 7

What’s normal temperature range for an adult?
Braden scale for skin breakdown

Answer 7

96.8-100.4; avg = 98.6
Braden: Lower scale = higher risk