in this chapter we're going to review assessment of the skin you need to remember that the skin is the largest organ of the body it serves to protect as a barrier between the internal and external environment to help protect from pathogens invading your patient it also provides sensation it helps with fluid balance temperature regulation vitamin D production and it aids in the patient's immune abilities the skin is made up of three layers it has an epidermal layer a dermis and a subcutaneous layer the epidermis is the outermost layer this is where keratinocytes are found which are substances that help Harden the nails and protect our skin on the outside this is also where melanocytes are found which are are substances that produce melanin it helps give the skin color and give the hair color this is also where Merkle cells are found that help with sensory transport and where the langerhan cells are found to help with adaptive immunity the dermal layer is the largest layer of the skin this is where the blood and lymph vessels are found nerves sweat and sebaceous glands as well as the hair roots and then the subcutaneous or the hypodermis layer is where the adipose and connective tissues are found as a patient ages there are a lot of normal changes that happen with the skin the skin will start to become thin the pigmentation will become uneven they're going to develop some wrinkling and skin folds and decreased elasticity their skin will become dry their hair will start to thin their skin will become more fragile which puts them at a greater risk for skin injuries and then sometimes they develop a reduced ability to heal they're not going to heal as quickly as a younger individual will on this slide you see some benign changes changes that we don't get worried about in an older adult client you can find these on page 1803 in your book the first one that you see there on the top left is a cherry angioma um this is just where vascular areas are going to come to the surface of the skin and create a reddish discoloration sometimes it's raised sometimes it's not um the second picture there that you see on the top is a solar lentigo or liver spots these are just light brown discolorations a lot of your patients will call these sun spots down on the bottom left you see saboric keratosis which are crusty brown spots that patients can get on their skin a lot of these patients will call these stuck-on patches sometimes they'll be kind of rough in appearance um then the next picture there that you see is example which are yellowish waxy deposits on the upper and lower eyelids um these are very thick um they're raised um and then over on that far right picture you see a picture of aging skin um this is just where the patient has those solar lentigo spots the skin is very thin they have wrinkling you can see that the the vessels in the hand are there at the surface and so that is what we typically see in our elderly patients over the next several slides I have listed out for you some reminders of things that you should look for on your assessment of your patient's skin you have to look the entire body over from head to toe you want to make sure that you not only are examining the surface of the skin but you're looking at the mucosa the scalp at the hair and nails as well you want to think about color temperature moisture and texture if the patient has any sort of lesions you want to make sure that you notate those lesions very closely you want to fill them you want to measure them you want to notice if there's anything draining out of them you want to notice the color of the hair the consistency of the hair is it coarse is it fine notice the distribution is it thick is it thin um and where the hair is located photographs are very helpful in determining or comparing skin issues from month to month or from year to year to determine if things are getting worse if things are getting better it helps you have a better evaluation of your interventions that are implemented then you need to also be very specific when you're Gathering a history and ask the appropriate questions to help you get better insight into what's going on you want to think about questions like when did the problem start are there any other symptoms what did it look like when it first appeared does it itch burn tingle have any kind of weird sensation does the patient have any allergies what makes it worse what makes it better is there a family history of similar issues are they using any medications um specifically topical but you also want to think about oral or systemic medications you also want to think about cosmetic products any creams or lotions that they may be applying to these areas on their skin what do they do for a living have they recently traveled all of those factors can directly impact what kind of changes you are seeing to a patient's skin on page 1803 there's a great chart that reviews some of these assessment features and then between Pages 1803 and 1807 there are some great pictures and and tables that highlight some of these assessment features as well down here at the bottom of this slide you see a link for an assessment video I encourage you to watch this assessment video if you have forgotten how to do a thorough skin assessment this video will Encompass the information over the next couple of slides and actually give you a visual of a nurse doing a very thorough skin assessment on a patient here are some reminders about variations in skin appearance as you are thinking about these terms you need to think about what they look like on a light-skinned patient versus a dark-skinned patient and you can review the chart on page 1805 in your book if you don't remember those details from physical assessment again just reminders about lesions and how to assess the lesions trying to differentiate between a primary lesion and a secondary lesion this here just gives you some reminders about how to document those lesions you need to make sure that you're notating color size location erythema edema pain um you need to notate the pattern of eruption and the distribution of the lesion and we'll talk about patterns and distributions on upcoming slides here you see a review of some of the different primary skin lesions you need to be able to differentiate between these types of lesions for testing purposes you can review these lesions on pages 1806 and 1807 in your book there's also a document posted in Blackboard that will help you with review of these lesions as well immacula is going to be very similar to a patch the macule will be smaller than a patch these areas are flat circular discolorations you're not going to be able to fill them if you run your hand across them examples of macules or patches will be freckles petechiae echymosis papules and plaques are very similar to each other the papule is much smaller than a plaque these areas are elevated they're palpable they're solid they're going to have circumcised or raised borders um and their color is going to vary examples of macules and plaques include nevi warts um plaques are going to include things like psoriasis um or actinic keratosis nodules are going to have raised borders um they're going to be about a a half of a centimeter up to about two centimeters a tumor is going to be larger than that and they're not always going to have very clear defined borders but you're typically going to be able to palpate their borders tumors are going to extend deeper into the dermal layer um than a papule will um examples of nodules and tumors will be like lipomas or squamous cell carcinomas um tumors will typically include [Music] um larger areas more invasive areas than a nodule does vesicles ambulae are very similar again a vesicle is smaller than a bullet both of these are going to have circumcised elevated borders but they're going to contain serous fluid they're going to be rather mushy in texture um examples of vesicles include herpes or um herpes simplex or herpes zoster varicella um sometimes a second degree burn that has a blister will form a vesicle fully examples include contact dermatitis poison ivy wheels are also elevated masses that have irregular borders um examples of quills include uticaria or hives wheels are usually temporary and last only a few hours insect bites will often cause Wheels pustules are going to be pus-filled vesicles or boy acne impetigo furbuncles or carbuncles will frequently cause pustules and cysts are encapsulated fluid-filled or semi-solid masses these can be things like cysts around a sebaceous gland or epidermoid cyst cysts usually have a very defined border though here you see secondary lesions you can find these in your book on page 1808 an erosion is where there's a loss of the epidermis it's very superficial examples include a ruptured vesicle or a scratch mark an ulcer results in skin loss beyond the dermis it may cause bleeding and scarring ulcers include injuries from venous insufficiency like pressure ulcers um a Fisher is a crack in the skin it's examples of a fissure include chapped lips or hands or tinea Pettis scales are flakes caused by dead epithelium that adheres to the skin surface it's usually a silvery white in appearance examples of scales include psoriasis dandruff other areas of dry skin or Rosia um crust is is just a scab it's residue that's left over after a vesicle ruptures so you can see this with illnesses like impetigo herpes um or maybe even eczema a scar is a healed wound um or a healed surgical incision the thing to remember with scars is that a younger or more fresh scar will be red or purple in appearance where a mature scar will be white or glistening in appearance a keloid is a hypertrophied scar area that is secondary to collagen formation during the healing process a keloid is an elevated irregular scarred area sometimes it's red in appearance we see a greater incidence of keloids in African-American individuals um atrophy is going to be thin dry transparent aged skin frequently you will see atrophy with arterial insufficiency and then latinification um is a thickening rough area on the skin due to repeated rubbing irritation or scratching so a lot of your patients that have contact dermatitis will suffer from lichenification here you see some of your vascular skin lesions again you can find these in your book on page 1811 petechiae are just red round or purple maccules they're small they're associated with bleeding Tendencies or emboli to the skin ecchymosis is a round irregular macular lesion it's larger than petechiae it's secondary to blood extravasations It's associated with trauma or bleeding tendencies Cherry angiomas are round they're notated a lot on the trunk and extremities but they remember can be a normal age-related change spider angiomas are going to be red arterial lesions they will blanch with pressure typically spider angiomas are associated with liver disease pregnancy or vitamin D deficient excuse me vitamin B as in boy deficiency and spider angiomas are rare to see below the waist typically they are in the upper body um talentia's are um going to have various shapes um these are notated on the um legs the anterior chest um and very frequently are associated with venous pressure increases um and so you a lot of times will hear people refer to these as varicose veins or a venous star these areas are going to be raised in appearance where your spider angiomas are typically going to be smooth to the skin you're going to be able to see the vasculature but you're not going to be able to feel it here you see some patterns of skin lesions linear lesions will occur in a line you're going to see linear formation with things like poison ivy or scabies annular or circular lesions you are going to see with diseases like ringworm arc form is where there will be formation of a partial ring or Arc diseases like syphilis will cause Arc formations zosteriform um is where you're going to have presentation that is linear along a nerve path so diseases like shingles will cause a zoster reform formation group is just where you have lesions that are clustered together discrete it's where they are separate and distinct mosquito bites would be examples of discrete formations there's space between them and then confluent are lesions that are merged together there's a lot of separate lesions but they're touching each other there are a lot of consequences to the skin from systemic disease processes diabetes is one of those disease processes that frequently causes changes to the skin due to circulation and issues with cell nutrition diabetic dermopathy is a frequent occurrence with diabetes this is where the patient will have lesions on the extremities especially on those bony prominences that are going to start out as small red bumps typically smaller than a pencil eraser and they're going to grow to become scaly and leave brownish and slightly depressed scars on the skin stasis dermatitis is an exhibitous eruption on the lower legs in patients with venous insufficiency the skin suffers from lack of nutrition and becomes very dry and frail with stasis dermatitis and then leg and foot ulcers a lot of times of course can lead to infection and the need for amputation for these patients your HIV patients can get a capacity sarcoma you may also see facial molluscum contagiosum or oral candidiasis as well as a number of other skin infections in patients that have HIV skin infections can be from bacterial fungal or dermaphite sources typically if a skin infection is bacterial in nature it's going to resemble a small pimple-like place frequently you see these lesions on the legs abdomen or buttocks they may form an abscess and become invasive fungal infections are typically going to be found in moist areas so under the breast in the upper thighs in the axilla dermaphite infections are typically going to be very dry in appearance there might be some mild redness typically your germifi infections are going to be found on the toenails and in the feet area there are several diagnostic studies that can be done on the skin a biopsy of course is done to examine for malignancies a tissue sample is going to be gathered and looked at under a microscope biopsies can be a shave procedure a punch a seizure or we can actually go in and and surgically remove a section of tissue to send off to the lab for further testing patch testing is allergy testing Um this can be done in several different ways by applying a small sample of a suspective allergen to the patient's skin and observing the patient to see what kind of reaction they have if a patient has patch testing you should always have emergency medications available just in case the patient has an anaphylactic response a skin scraping is typically done for fungal infections this is where they're going to take a a small blade or scalpel and pull off um some skin samples to look for things like scabies and then a a tank smear um is typically used anytime the patient has a blistering condition like herpes or varicella the provider will take a sterile Q-tip most of the time and gather fluid from that blistering area place it on a glass slide and examine it under a microscope or send it off to the lab and then a Woods light exam um is a special lamp that has UV lights to help differentiate between the dermal and epidermal layers um so that we can determine the depth of injury in a certain area