46 terms

Assessment Skin

3-4 weeks
epidermis, dermis, subcutaneous
keratinocytes, melanocytes, langerhan cells )immune response) merkel cells (touch)

The stratum basale is the layer in which new keratinocytes are produced. These cells migrate to the corneum ever 3-4 weeks, allowing for cell turnover.
contains protein, collagen, elastin, reticulin
fibroblasts, mast cells release histamine, and macrophages
eccrine sweat glands are all over the body, though most concentrated on the palms and soles. The respond to external temperature and stress
apocrine glands are located in the axillae, genitals, and on the areola. These respond to stress and secrete pheromones
dermis hair
The sebaceous glands are located near the hair follicle. These glands produce sebum to lubricate and protect the hair and the skin. When our bodies want to prevent heat loss from occurring, the arrector pili muscles respons by secreting sebum and causing our hairs to stand up. This method traps heat, and produces what we like to refer to as "goosebumps".
dermis nails
The normal finding is a Schamroth's window
fatty layer, adipocytes, protective layer
skin changes with age
Lanugo- fine downy hair, disappears within the first few weeks, small amounts of terminal hair
Less subcutaneous tissue, lose heat easily
Thickness varies with gestation,color changes more easily since its not as thick as adults
Adolescents go through rapid hormonal changes during puberty. Changes in hair distribution occur. And since adolescence is considered to be a stressful time, sweat glands are more active during this period. As individuals get closer to adulthood, the dermis layer thins.
epidermis- thins as collagen production and formation decreases, skin more prone to atrophy and injury. Topical medications have poor absorption.
Skin- less elastic, wrinkles.
Melanocytes decrease in number ineffectiveeffectively (more gray hair,pale skin).
The melanocytes that remain increase in size, leads to age spots.
In the dermis layer, blood vessels become more friable, leading individuals to bruise or bleed more easily.
Less sweat production- hard to regulate temp
Hair throughout the body thins
Finally the subcutaneous layer becomes thinner, decreasing the amount of padding covering underlying structures and also affecting thermoregulation, making elderly individuals more prone to hypothermia.
inspection and palpation
color- erythema, pallor, cyanosis, jaundice
inspection and palpation
It is important to assess for subtle changes in the skin. You can gather a lot of valuable information about what is going on with a patient by doing a basic assessment of their skin.
What is the patient's color? Is their skin one uniform color, or is one area different?
Palpation allows you to assess for temperature. It is recommended that you use the back of your hand. Again, you are looking to see if the temperature is uniform. If one area of the body is cooler than the other, what would you be concerned about? What about if one area is warmer?
In the ED we often assess for the presence of cellulitis. In patients with cellulitis, the affected area is erythematous and is noted to be warmer than the rest of the body.
Assessing moisture may help indicate a patient's hydration status. Texture of skin can vary with age, ethnicity, or may be affected by the presence of certain underlying conditions.
Skin Turgor is also an important component of palpation. Does anyone know what turgor is used to check for? (elasticity and hydration). To check turgor, you pinch a fold of the skin, often using the patient's forearm. When you let go, the skin should quickly return to it's original form- within 3 seconds. Poor turgor indicates a delay in the time the skin takes to recoil, so longer than 3 seconds. Tenting refers to the appearance of skin with poor turgor. So imagine if you pinch the skin and it does not return to it's original form, it sort of looks like a tent. This is seen more often in elderly patients because their skin has lost its elasticity. And is also seen in severely dehydrated patients.
Skin lesions -any abnormality on the skin.
Primary lesions- external or internal environment of the skin. Secondary lesions are a result of changes to primary lesions.

inspection and palpation. You want to assess the size in centimeters, the shape, the color, and the texture. Is the lesion palpable, meaning it's raised, or is it flat and if your eyes were closed you would not even know it was there? Does the lesion blanch, meaning does it lose its redness when you press on it? Areas that do not blanch are usually due to the presence of red blood cells outside of the blood vessels. A stage 1 pressure ulcer is an example of a time where you would have erythema that does not blanch. Pressure ulcers will be discussed later on.
Flat non palpable lesions
macules and patches
Macules are < 1cm; whereas Patches are > 1cm
Change in skin color
Freckles, mongolian spots
red, small
red to purple, larger than petechiae
yellow- older
rub it and it goes away
concerning if it doesnt blanche, doesnt go away when rubbing
raised palpable lesions
< 1cm
Solid elevation
Ex. Moles,
molluscum contagiosum
into dermus layer
1-2 cm
Ex. Lipoma
Cysts are elevated, circumscribed, and encapsulated lesions that vary in size. They are deeper than papules, extending into the dermis or subcutaneous layers. Cysts are filled with liquid or semisolid material.
Tumors are large, solid, often well demarcated lesions that extend into at least the dermis, and often to deeper layers
> 2cm
May be well defined
Benign or malignant
Ex. Vascular tumors
vesicles and bullae
Vesicles and Bullae are similar in characteristics, but vary in size. Bulla, which is actually Latin for "bubble" is basically just a large vesicle. Both vesicles and bulla are superficial, elevated lesions that contain serous fluid.
The picture on the right shows the classic vesicles that occur in hand-foot-and-mouth disease, which is a viral illness common in young children.
superficial, red, pus,
infection at hair follicles- folliculitis
plaques wheals
Plaques are superficial plateau-like elevations of the skin that are firm and have a rough, scaly feel to them. Wheals are also superficial, and vary in size and shape. They can be either circumscribed or irregularly shaped.
Discrete means that the pattern is random. Grouped lesions are found in clusters. Confluent lesions run together.
Linear obviously means arranged in lines. Annular lesions are shaped like a ring,
Acriform lesions are partial rings.
Bullseye lesions are round with a central clearing.
diffuse just means the lesions are all over, versus being localized.
pressure ulcer
2 hrs of pt in same position

Friction occurs when moving patients. The skin is irritated when being pulled across bed linens. Friction can damage the outermost layer of the epidermis, making the layers underneath the statum corneum more suceptible to breakdown.

prolonged moisture softens the epidermis, making the skin more fragile and likely to break down.
pressure ulcer risks
friction, shear, impact, heat, moisture, posture
intrinsic- immobility, sensory loss, age, disease, body type, nutrition, infection
Braden risk assessment scale
Turn and reposition every 2 hours
Keep head of bead flat when moving
Use drawsheets
Keep skin clean and dry
Specialty mattresses

The Braden scale should be done on every patient at least once every 24 hours, though standards of practice vary by unit, and ICUs often assess this every 12 or even every 8 hours, as those patients can have a rapid change in their condition.
Turn and reposition every 2 hours.
The head of the bed should be flat when not contraindicated, because this decreases a patient's risk for shearing forces when you are moving them up in bed.
Drawsheets also decrease both friction and shear, because you can pull the sheets tight and ensure that the surface the patient is being transferred on is smooth and does not cause damage to their skin.
Keeping the skin clean and dry, especially with patients who are incontinent, helps prevent moisture from accumulating on the skin, making it more prone to breakdown. For patient's with frequent incontinence, you can request barrier cream to prevent breakdown in those areas.
And for those patients who have medically necessary restrictions that keep you from being able to turn and reposition them every 2 hours, you can request a specialty mattress that helps prevent skin breakdown.
braden scale
The Braden Scale is a standard of practice used to assess an individual's risk for pressure ulcers.
It looks at: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. .
16 or less- risk
12 or less- high risk
pressure ulcer assessment
It is the standard to measure pressure ulcers in centimeters. Measurement is important when monitoring if the area is resolving versus worsening. Is there drainage present? If so, what is the color of the drainage? Is it serous, bloody? Is there pus? Does the drainage have a foul smell? How much drainage is there? It is important to look for tracts and tunneling. If you note either of these, you should use the clock system to document their location. For example, tunneling noted at 2'Oclock. Finally it is important to assess the skin surrounding the wound, as this skin is highly susceptible to breakdown.
stage 1
only involves epidermis
stage 2
Stage 2 pressure ulcers are still considered to be superficial, but are partial thickness, meaning they involve the epidermis and the dermis. An open sore, such as a blister, forms. The peri-wound area is often erythematous in this stage.
stage 3
full thickness- epidermis, dermis, subcutaneous
peri-would involvement fascia involved
stage 4
Full-thickness with extensive involvement of underlying structures
Peri-wound involvement
Drainage is present
Necrotic tissue
Certain pressure ulcers are unstageable. These ulcers are covered in eschar and exudate and need debridement to determine which structures are involved so the ulcer can be properly staged.
. 1st degree burns involve the epidermis. 2nd degree burns involve the dermis, and can be superficial partial thickness or deep partial thickness burns. 3rd degree burns are full thickness, involving the subcutaneous layers and often extending to the underlying muscle, tissues, and bone. Unlike first and second degree burns, third degree burns are painless because you have destroyed the layer of the skin made up of sensory receptors.
Burn Surface Area or Total Burn Surface Area
head, arm -4.5%
chest -18%
leg 9%

genitals 1%
skin cancer
Skin cancer is the most common type in United States
1 in 5 people will develop skin cancer in their lifetime
1 million new cases are diagnosed each year
Most cases are basal cell or squamous cell carcinoma
However, melanoma kills 8,000 individuals each year

Skin cancer is on the rise, with tanning beds being a lead culprit
Going to a tanning bed 10x per year increases your risk of malignant melanoma by eightfold!
Melanoma is considered so deadly because the collection of melanocytes extends through the dermis and often times reaches the lymphatic system and blood vessels.
risk factors for skin cancer
Fairer skin, eyes, and hair
Chronic exposure to the sun, especially during peak hours
Personal history of sunburns
Use of indoor tanning
Personal or family history
fitzpatrick classification sclae
Always burns, never tans, sensitive to UV exposure.
II: Burns easily, tans minimally.
III: Burns moderately, tans gradually to light brown.
IV: Burns minimally, always tans well to moderately brown.
V: Rarely burns, tans profusely to dark.
VI: Never burns, deeply pigmented, least sensitive
Mole assessment
A asymmetrical shape
B irregular border
C changes in color
D diameter > 6mm
E evolving, elevation
wound healing
Phase 1- Inflammation
Begins at time of injury; lasts up to 5 days
Hemostasis -> Clot formation -> Inflammatory Response
Phase 2- Proliferation
Begins between days 2 and 5; lasts up to 3 weeks
Neovascularization- new capillaries grow
Granulation tissue- greenish
Phase 3- Remodeling and Maturation
Begins around 3 weeks; lasts up to 1 year +
Increased tensile strength
Scar formation
more collagen to inc strength
complications of wound healing
Dehiscence-opening of a wound
Evisceration-which is protrusion of the viscera through the wound
Fistula- abnormal passage