Skin Physical Assessment Flashcards
3 inspection
- skin integrity
- skin colouration
- skin lesion
Inspection: Skin integrity abnormal result
pressure injury:
1. reddness, intact skin
2. Open wound, partial skin thickness
3. skin loss
4. tissue loss
(Unstagable: eschar, dead tissue)
Inspection: Skin colouration abnormal result
Rash, pallor, white patches, albinism, cyanosis
Inspection: Skin colouration normal result
freckles, evenly coloured, suntanned area depended by sun exposure
Inspection: Normal Skin integrity result
intact skin without redness
Inspection: Skin lesion abnormal result
keloid, vesicle, papule, pustule, urticaria
Inspection: skin lesion normal result
smooth skin without lesion
normal: birthmark, healed scar, freckles
Inspection: Skin lesion procedure （for skin cancer）
ABCDE: asymmetry, broaders, colouration, diameter, evolve
8 skin palpation
- skin temperature
- skin mobility; tugor
- skin thickness
- skin texture
- edema
- skin moisture
- skin lesion
Palpation: Skin lesion procedure
note for mobility, consistency, drainage, tenderness
Palpation: Skin lesion abnormal result
fixed & tender: +/- cancer
tender: +/- infected lesion
Palpation: Skin lesion normal result
no lesion palpated
Palpation: Skin texture procedure
use the plam area of three middle fingers to palpate
Palpation: Skin texture normal result
even & smooth skin
Palpation: Skin texture abnormal result
rough & dry skin: =/- hypothyroidism
Palpation: Skin thickness procedures
use fingers to assess
Palpation: Skin thickness normal result
normally thin
(Callucus) thick & rough section with constant pressure
Palpation: Skin thickness abnormal result
very thin: +/- steroid therapy
Palpation: Skin moisture procedure
assess skin moisture esp skin folds, e.g. under the breast, groin, belly
Palpation: Skin moisture abnormal result
- increased moisture/ sweat: fever/ hyperthyroidism
- Dry: dehydration
- Clammy: shock/ hypotention
Palpation: Skin moisture normal result
elderly: dryer skin (decreased skin sebum production)
No dryness/ scalping
Palpation: Skin temperature procedure
feel dorsal area tmeperature
Palpation: Skin temperature normal result
warm/ cold skin at cold environment
Palpation: Skin temperature abnormal result
Cold: shock/ poor circulation
Very Warmth: fever/ hyperthyroidism
Palpation: Skin mobility & turgor procedure
gently pinch skin
Palpation: Skin mobility & turgor normal result
mobile with elasticity & quickly return to original shape
Eldery: decrease collagen > loss of skin turgor
Palpation: Skin mobility & turgor abnormal result
decreased mobility: edem
decreased turgor: dehydration
Palpation: what are Skin mobility & turgor
skin mobility: how easy to pinch skin
skin turgor: elasticity/ how quick skin return to original shape
Palpation: skin edema procedure
use thumb to press down skin (areas: ankle, feet, tribial)
Palpation: skin edema normal result
rebound after release pressure without indented
Palpation: skin edema abnormal result
severity of pitting edema by depth of indentation: 1+ (2mm), 2+ (4mm), 3+ (6mm), 4+ (8mm)
Non-pitting edema: hypothyroidism
