Skin Assessment

INTEGUMENTARY SYSTEM

 Largest organ
 Protects from trauma & bacteria
 Prevents loss of water & electrolytes
 Sensing temperature, pain, touch &
pressure
 Regulating body temperature-
 Synthesizes vit.D
 Wound repair
 Formed from KERATIN &
matrix cells in the DERMAL
AREA
 Provides warmth, protection,
& sensation to the underlying
systems
 Balding- age
NAILS – for protection to the
distal surface of the digits
Obtaining Health History
 Skin – itching, rashes, lesions, pigmentation
abnormalities, allergies?, skin products?
 Hair – hair problems, sudden or gradual? Air
loss or hair growth? hair dye?
 Nails- growth, color? Maybe due to infection or
nutritional deficiencies, stress

 -rash – is a change in skin which affects its

color, appearance or texture
 -lesion – any abnormality in the tissue of an
organism (damage)
Assessment
 INSPECTION & PALPATION
 Well lit, warm, wear gloves
 Equipment:
 Ruler, tongue blade, penlight, wood’s
lamp, magnifying glass
 Color
 Texture
 Turgor
 Moisture
 Temperature
I. COLOR – uniformity, hypopigmented,
hyperpigmented areas

Cyanosis –
conjunctiva, palms, soles, buccal mucosa,
tongue
Erythema
Pallor
Petechiae
Diaper Rash
Measles Rash
Dermatitis
Mongolian Spots
Texture
 Rough & smooth

TURGOR – elasticity – represents pt’s

hydration status
DHN & edema – accumulation of fluid
Poor skin turgor,
Return quickly to the original shape
If over 30 seconds (slowly)
Edema – tented/ imprint thumb → release
pressure observe indentation
Edema
 Non- pitting & pitting

 0
 1+ = 2mm
 2+ = 4mm
 3+ = 6mm
 4+ = 8 mm
moisture
 skin is dry – with minimum perspiration
 Body temp –
 Diaphoresis – profuse production of
perspiration

TEMPERATURE – warm & equal, bilateral

 Hands/ feet – slightly cooler
 Hypothermia
 hyperthermia
lesions
 N- birthmarks (flat, tan, brown red),
 freckles(small flat, face, arms, back, red
brown to brown),
 nevi/ moles (flat/ raised, pink, tan, dark
brown)
 Types of Lesions page 86
 MOST COMMON:
 A. Macule – NON PALPABLE
 B. Papule- PALPABLE
 C. Vesicle- FLUID- FILLED
A. NON-PALPABLE
 1. MACULE- <1cm in diameter eg.
freckles
 2. PATCH- > 1 cm in diameter; vitiligo
Macule

PATCH
VITILIGO
II. Palpable
 A. papule – solid, elevated <0.5cm ex.
Warts, elevated nevi
 B. plaque - >0.5cm
 C. Nodules – deeper than papules –
dermis/ subcutaneous ex. Hemangioma
0.5 – 2 cm
 D. tumor – same as nodule > 2cm
 E. Wheal – localized edema (epidermis);
insect bite
Papule
WHEAL
III. Fluid-filled
 A. vesicle – accumulation of fluid bet upper
layer of the skin<0.5 cm ex. Herpes simplex,
chickenpox
 B. Bullae- same as vesicle – 0.5cm
ex. Contact dermatitis, impetigo
C. pustule- vesicle/ bullae – filled with pus <
0.5cm; acne, impetigo
D. Cyst- encapsulated fluid-filled/ semi-solid
mass – in subcutaneous tissue/ dermis
Ex. Sebaceous cyst
Vesicle
PUSTULE
Illuminating lesions pg. 86
 Macule or papule (with shadow)
 Solid or fluid-filled (transilluminate a red glow)

 Wood’s lamp
 Bluish green→ fungal infection

 BORDER – Regular or irregular ( malignancy)

 Color – nevi – tan/ brown → multiple shades of
tan/ dark brown, black, red, white, blue
(malignancy)
Lesion Configurations
 Note for: characteristics, pattern,
location and distibution, border (regular/
irregular – benign/ malignant)
 GROUPING/ ARRANGEMENT
lesion configurations page 87
1. Discrete - separate and distinct
2. Confluent - merged that indvl lesions are not
visible or palpable
3. Annular - arranged in singke ring or circle
4. Arciform - it arcs or curves
5. Grouped - clustered together
6. Linear - forms a line
7. Polycyclic - multiple circles
8. Reticular - forms a meshlike network
SKIN ABNORMALITIES page 91

Café-au-lait Spots
Cherry Angioma
Hemangioma/ port-wine stains/
birthmarks
Stage I
Stage II
Stage III
Stage IV
Purpuric Lesion
Urticaria
Vesicular Rash
HAIR
Alopecia
Hirsutism
Figure 30-9 The parts of a nail.
Figure 30-10 A, A normal nail, showing the convex shape and the nail plate angle of about 160 degrees; B, a spoon-shaped nail, which may be seen in clients with iron deficiency anemia; C,
early clubbing; D, late clubbing (may be caused by long-term oxygen lack); E, Beau’s line on nail (may result from severe injury or illness).

61
Figure 30-10 (continued) A, A normal nail, showing the convex shape and the nail plate angle of about 160 degrees; B, a spoon-shaped nail, which may be seen in clients with iron
deficiency anemia; C, early clubbing; D, late clubbing (may be caused by long-term oxygen lack); E, Beau’s line on nail (may result from severe injury or illness).

62
Figure 30-10 (continued) A, A normal nail, showing the convex shape and the nail plate angle of about 160 degrees; B, a spoon-shaped nail, which may be seen in clients with iron
deficiency anemia; C, early clubbing; D, late clubbing (may be caused by long-term oxygen lack); E, Beau’s line on nail (may result from severe injury or illness).

63
Figure 30-10 (continued) A, A normal nail, showing the convex shape and the nail plate angle of about 160 degrees; B, a spoon-shaped nail, which may be seen in clients with iron
deficiency anemia; C, early clubbing; D, late clubbing (may be caused by long-term oxygen lack); E, Beau’s line on nail (may result from severe injury or illness).

64
Figure 30-10 (continued) A, A normal nail, showing the convex shape and the nail plate angle of about 160 degrees; B, a spoon-shaped nail, which may be seen in clients with iron
deficiency anemia; C, early clubbing; D, late clubbing (may be caused by long-term oxygen lack); E, Beau’s line on nail (may result from severe injury or illness).

65
Beau’s lines

Muehrcke’s lines
Clubbing of Fingers
Koilonychia
Onycholysis
Terry’s nails
NEUROLOGIC SYSTEM
NEUROLOGIC SYSTEM
5 AREAS:
1. MENTAL STATUS
2. CRANIAL NERVE FUNCTION
3. SENSORY
4. MOTOR
5. REFLEXES
NEUROLOGIC SYSTEM
I. MENTAL STATUS & SPEECH
 A. LOC
 -ALERT
 -LETHARGIC
 -STUPOROUS
 -COMATOSE
 B. APPEARANCE & BEH
 C. SPEECH- DYSARTHIA
 D. COGNITIVE FUNCTION
 E. CONSTRUCTIONAL ABILITY
CRANIAL NERVES
I-OLFACTORY - s
II-OPTIC - s
III- OCCULOMOTOR - m
IV- TROCHLEAR - m
V- TRIGEMINAL - b
VI- ABDUCESNS - m
VII- FACIAL - b
VIII- ACOUSTIC - s
IX- GLOSSOPHARYNGEAL - b
X- VAGUS - b
XI- ACCESSORY - m
XII- HYPOGLOSSAL - m
CN 1 – Olfactory nerve (smell)
CN II – Optic nerve – ask to read (largest to
smallest) , CONFRONTATION Test
CN III (Oculomotor – extraocular movement,
elevation of eyelids & pupillary constriction) -
PTOSIS
CN IV ( troclear – down & in eye movement ), CN
VI (Abducent –lateral eye movement)
6 cardinal gazes: LS, LL, LI, RS, RL, RI
NYSTAGMUS – ability to hold the gaze
 CN V – trigeminal (S & M)
S – wisp of cotton (light touch to face)
 Pin ( pain perception)
 Sharp & dull
M – clench his teeth (palpate the masseter
& temporal muscle)
 CN VII – facial (S & M)
S – taste (anterior of the tongue)
M- smile, frown, raise eyebrow

CN VIII – acoustic
Cochlear (hearing) – whisper test
Vestibular (balance) – Romberg’s test
 CN IX – Glosopharyngeal - salivation,
taste (posterior 1/3 of the togue)
 CN X – Vagus - swallowing, voice
quality

CN XI – accessory (M) – hand against the

cheek
Trapezius muscle – hands on the shoulder,
then ask to shrug his shoulder
 CN XII – Hypoglossal – tongue
movement (@ midline, no tremors or
fasciculations
 Push tongue against the cheeks (apply
resistance)
SENSORY FUNCTION
1. PAIN – sharp & dull (fingers, shoulders, toes, thighs & trunk)
2. LIGHT TOUCH – wisp of cotton
3. VIBRATION – tuning fork (bony prominence); interphalangeal
joint of great toe
4. POSITION – move toe up or down
5. DISCRIMINATION – ability of cerebral cortex to interpret &
integrate information
*STEREOGNOSIS – ability to discriminate shape, size, weight, texture
& form of objects by touching & manipulating
*GRAPHESTHESIA – draw number on the palm
*POINT LOCALIZATION – touch limb
*2-POINT DISCRIMINATION – in two contralateral areas
EXTINCTION – failure to perceive touch on one side
MOTOR FUNCTION
I. MUSCLE TONE – ROM (shoulder, Leg)
-external rotation
2. MUSCLE STRENGTH- extend arms, palms up (30
secs); check for pronation & downward drift
3. CEREBELLUM- coordination & balance
▪ Romberg’s test -walk
▪ Test for extremity coordination – nose & finger
▪ Cerebellar function - Rapidly alternating movement –
thumb & fingers
▪ Palms up & down
▪ Alternately tap foot against the palm
ASSESSING REFLEXES
I. DEEP TENDON REFLEX (0, +1, +2, +3,
+4)
1. Bicep Reflex
2. Tricep Reflex
3. Patellar Reflex
4. Brachiradialis Reflex
5. Achilles Reflex
Bicep Reflex
TRICEP REFLEX
PATELLAR REFLEX
BRACHIORADIALIS REFLEX
ACHILLES REFLEX
BABINSKI REFLEX
Abdominal Reflex
Primitive Reflex
1. Grasp Reflex
2. Snout Reflex
3. Sucking Reflex
4. Glabella Response
Abnormal Response
1. Altered LOC
2. Cranial Nerve Impairment- A. Olfactory
B. Visual Impairment
C. Auditory Impairment
D. Speech & Swallowing
E. Constructional Impairment-
* Apraxia
* Agnosia,
3. Abnormal Muscle Movement –
*TICS
*TREMORS
*FASCICULATION
4. Abnormal Gaits-
A. Spastic Gait
B. Scissors Gait
C. Propulsive Gait
D. Steppage Gait
E. Waddling Gait
QUIZ
 1. REFERS TO THE INVOLUNTARY
MOVEMENT OF THE EYE
 2. THESE ARE FINE TWITCHINGS IN
SMALL MUSCLE GROUPS AND ARE
ASSOCIATED WITH LOWER MOTOR
NEURON DYSFUNCTION
 3. Gait as a result of footdrop
 4. FAILURE TO PERCEIVE TOUCH ON
ONE SIDE IS KNOWN AS?
 5. WHAT IS THE LEVEL OF
CONSCIOUSNESS OF A PATIENT
WHO IS DROWSY AND HAS DELAYED
RESPONSES TO VERBAL STIMULI.
 6. REFERS TO THE DIFFICULTY IN
FORMING WORDS
 7. CRANIAL NERVE MAINLY FOR THE
LATERAL MOVEMENT OF THE EYE
 8. WHAT IS CN VIII
 9. refers to unequal pupils
 10.REFERS TO THE REFLEX THAT
INVOLVES THE UPWARD MOVEMENT
OF THE GREAT TOE & FANNING OF
THE LITTLE TOES
 11. inability to identify common object
 12. primitive reponse elicited by tapping
the bridge of the nose
 13. reflex elicited by using an applicator
stick to stimulate the inner thigh
 14. most sensitive indicator of one’s
neurologic damage
 15. inability to understand written or
spoken words

Aphasia