1. Hess, Cathy Thomas BSN, RN, CWOCN

Article Content

Much like the criteria for performing a wound assessment, performing a skin assessment is of critical importance when assessing the patient. Capturing the patient's general physical condition, performing careful inspection and palpation of the skin, and documenting findings constitute the components of a physical assessment of the skin. Performing the following may be helpful when conducting a review of the patient's skin history.


* Obtain a history of the patient's skin condition from the patient, caregiver, and/or previous records. Review the detailed family history with the patient, and make sure all skin conditions are reviewed.


* Obtain a history of the patient's bathing routines and products. Capture the different soaps, shampoos, conditioners, lotions, oils, and other topical products used on a routine basis. Changes in skin may appear as xerosis or skin dryness, pruritis, wounds, rashes, change in skin pigmentation or color, and so on. A change in the patient's nail structure may be a sign of a systemic condition. Observe for changes in thickness, splitting, discoloration, breaking, and separation from the nail bed.


* Capture all allergies to medications, topical skin and wound care products, and food, to name a few.


* Ask if the appearance of the skin changes with the seasons.



Physical Assessment

Perform a physical skin assessment including skin temperature, skin dryness, itching, bruising, and changes in texture of the skin and nail composition. Assess the skin for color and uniform appearance, skin thickness, skin symmetry, and other lesions.


Lesions generally can be categorized as primary and secondary lesions. Primary lesions are those present at the initial onset of the disease:


* bulla: a vesicle greater than 5 mm in diameter


* cyst: an elevated, circumscribed area of the skin filled with liquid or semisolid fluid


* macule: a flat circumscribed area of color change that is brown, red, white, or tan


* nodule: elevated, firm, circumscribed, and palpable; can involve all layers of the skin; and is larger than 5 mm in diameter


* papule: elevated area of the skin; palpable, firm, circumscribed lesion generally less than 5 mm in diameter


* plaque: elevated, flat-topped, firm, rough, superficial papule greater than 2 cm in diameter; papules can coalesce to form plaques


* pustule: elevated and superficial, similar to vesicle but filled with pus


* vesicle: elevated, circumscribed, superficial, fluid-filled blister less than 5 mm in diameter


* wheal: elevated, irregularly shaped area of cutaneous edema; solid, transient, changing, and of variable diameter; red, pale pink, or white in color.



Secondary lesions are the result of changes over time caused by disease progression, manipulation (scratching, rubbing, picking), or treatments:


* crust: dried serum, blood, or purulent exudate, slightly elevated, of variable size


* excoriation: loss of epidermis; linear area usually due to scratching


* lichenification: rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching (eg, chronic eczema, lichen simplex)


* scale: heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, of variable size, and silver, white, or tan in color.



Dry Skin

Dry skin affects approximately 59% to 85% of persons older than 64 years. Many factors contribute to dry skin. More than 70% of patients who are hospitalized have dry skin, and 90% of residents older than 65 years in nursing homes have dry skin.


Additional causes that play a role in dry skin include the environment (eg, low humidity, sheets, gowns, elastic stockings/hose), resident's habits (eg, smoking, alcohol, poor eating), diseases (eg, allergies, heart disease, diabetes, etc), medications (eg, diuretics, antibiotics), and skin cleansers (eg, soaps too drying to the skin, ineffective lotions).


Clinicians must document the presence of skin condition, erythema, itching, scratching, skin weeping, skin blistering, bruising, primary lesions, secondary lesions, and open wounds.


Xerosis and Pruritus

Conditions such as xerosis and pruritus have been documented as the most common complaints encountered in nursing homes, with xerosis being the most frequent cause of pruritus. Xerosis, or dryness, is a common characteristic of older skin. Xerotic skin may be rough and scaly, with dryness occurring most often over the lower legs, hands, and forearms. Skin dryness may be triggered by medications or chronic illnesses and not usually associated with a dermatologic condition or systemic disease.


Dry skin is associated with up to 85% of pruritus. Pruritus can be described as a sensation of intense itching. Scratching can cause excoriations, which may progress to secondary eczema or become infected.


Source: Hess CT. Clinical Guide: Skin & Wound Care. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.