Assessing Skin Color

Introduction

• Assessing skin color is an important part of patient evaluation in nursing.
• Documentation should be by exception: know normal vs abnormal skin conditions.
• Follow your facility's policies and procedures for documentation.

Key Terms in Skin Color Assessment

Pallor

• Description: Pale skin, lack of color.
• Causes:
  • Low hemoglobin (anemia)
  • Low blood volume (hypovolemia)
  • Compression
• Assessment Areas:
  • Face and exposed skin
  • Conjunctiva (eye)
  • Lips
  • Nail beds (check capillary refill time)
• Implications: Lack of blood flow to the area.

Cyanosis

• Description: Bluish, grayish skin color.
• Causes:
  • Cold environment
  • Vasoconstriction
  • Cardiac or respiratory issues
• Types of Cyanosis:
  • Peripheral: Ears, fingers, toes, nail beds
  • Central: Lips, mouth, tongue, mucosal membranes (medical emergency)
• Implications: Localized hypoxia.

Erythema

• Description: Red or flushed skin.
• Causes:
  • Sunburn
  • Alcohol consumption
  • Fever
  • Infection
  • Injury or trauma
• Assessment Areas:
  • Face (cheeks)
  • Shoulders (sun exposure)
  • Areas of trauma or injury
• Implications: Vasodilation leading to increased blood flow.

Jaundice

• Description: Yellow or orange skin tone.
• Causes:
  • Liver or gallbladder dysfunction
  • Red blood cell destruction (increased bilirubin)
• Assessment Areas:
  • Sclera (eye)
  • Face
  • Palms and soles (darker skin tones)
• Implications: Bilirubin buildup in the body.

Expectations in Patient Assessment

General Assessment

• Capillary Refill: Pinch nail bed, expect refill ≤ 3 seconds.
• Hair Patterns: Note any unusual hair loss or growth.
• Skin Color: Compare to patient's normal healthy skin tone.
• Temperature: Use back of the hand, check both sides for symmetry.
• Skin Turgor: Pinch skin on forearm, clavicle, sternum, or hand.

Documentation by Exception

• Document only abnormalities or deviations from the expected normal.

Conclusion

• Proper assessment and documentation of skin color are critical in nursing.
• Use these assessments to guide further investigation and care.
• Remember to chart by exception and follow facility guidelines.