6.7 Skin: Inspection

Inspection of the skin can be performed with the client sitting upright on the exam table or lying in a supine position. If you are doing a focused assessment, position the client so that you have the best visibility of the affected area. Use a bright light or a pen light if needed. Shadows and dark lighting may alter your visualization of the affected area and provide information about the elevation of a lump.

If you are doing a complete assessment, use a systematic approach and proceed cephalocaudally (head-to-toe) to ensure comprehensiveness. If the client has identified a specific concern, inspect that area first. If you are doing a complete assessment when the client has no specific concerns, inspect the face, arms/hands, back, abdomen, chest, and legs/feet. Always inspect the anterior and posterior side; for example, for the arms, ask the client to raise their hands/arms in front of them with their palms facing down and then turn palms up so that you can inspect both sides. Similarly, for the legs, inspect the anterior and then have the client roll over so that you can inspect the posterior. You may need to seek assistance to reposition a client that is immobile or has difficulty moving.

Keep in mind that the best control for comparison is the client’s own body, so always compare bilaterally.

Skin inspection involves the following steps:

1. Inspect the skin for symmetry and color using both a generalized and localized approach. To visualize general color, step back and take note of their general appearance; for a localized approach, inspect specific regions. Mucous membranes, palms, sclera, and regions around the mouth can all be telltale signs for centralized color variations. Pay special attention to skin folds such as under the breasts, groin, and in between fingers and toes. Always examine distal extremities for discoloration. Table 6.4 lists common color variations. Skin color varies widely from dark to light shades including black, brown, yellow, and white shades. These colors are affected by many factors. The biggest factor is how much melanin is produced by the body’s melanocytes; this also affects hair and eye color. Additionally, the circulating hemoglobin affects skin color and the underlying connective tissue.

• • Normally, skin color is evenly distributed with no variations; clients with darker skin tones will have lighter colored palms and soles of feet. You may observe birthmarks, which are visible upon birth and include a wide array of sizes and colors (brown, black, blue, red, pink and purple). Most are flat and some fade over time. You should document them, describing their location and description particularly, since some can look like bruising.
  • If you notice variation in skin color, note the location, color, and other characteristics of the discoloration.

2. Inspect the skin for lesions. When conducting a skin assessment, it’s essential to distinguish between primary and secondary lesions. Understanding these categories helps in identifying and assessing skin conditions effectively. Typically, lesions are associated with pain because they generally involve the epidermis and/or dermis which are both innervated (supplied by nerves). However, nerve damage may limit sensation and therefore pain to the region. Clients with nerve damage are at increased risk for secondary infections and lesions because they are not restricted by pain at the site. If lesions are present, describe the location and characteristics in detail, including size, color, movability, borders, elevation, drainage, and pain levels. 

Primary Lesions:

• Definition: Primary lesions are the initial, direct result of a disease process or a response to an injury. These lesions are often the first observable changes in the skin and provide critical clues to the underlying condition.
• Examples:
  • Macules: Flat, small (less than 1 cm) areas of discoloration on the skin. They can be pigmented (e.g., freckles) or non-pigmented (e.g., vitiligo spots).
  • Papules: Small, raised, solid lesions less than 1 cm in diameter. These can be either pigmented (e.g., certain moles) or non-pigmented (e.g., warts).
  • Moles (Nevi): Typically pigmented lesions that can be macules (flat) or papules (raised). Moles are common and usually benign, but changes in their appearance should be monitored closely.
  • Vesicles: Small, fluid-filled blisters less than 1 cm in diameter. Common in conditions like herpes simplex.
  • Pustules: Raised lesions filled with pus, often seen in conditions like acne.

Secondary Lesions:

• Definition: Secondary lesions develop from primary lesions or are caused by external factors such as scratching, infection, or the healing process. They often indicate the progression of a disease or the body’s response to an initial lesion.
• Examples:
  • Scales: Flakes or dry patches made up of excess dead epidermal cells. Commonly seen in conditions like psoriasis.
  • Crusts: Dried blood, serum, or pus on the surface of the skin, often formed after a blister or pustule breaks.
  • Ulcers: Deeper losses of skin, often extending into the dermis, seen in conditions like pressure sores.
  • Scars: Fibrous tissue that replaces normal skin after an injury or surgery, indicating the skin’s healing process.

If the client has expressed concern about specific moles, check them first. Otherwise, inspect the face, arms/hands, back, chest, abdomen, and legs/feet for the presence of nevi. If you observe any, use the ABCDE mole screening mnemonic (Table 6.5 and Figure 6.4); this is vital to screen for melanoma, a life-threatening skin cancer in which early detection is essential (Rigel et al., 2005). Most moles are benign, but they can become malignant: people with more than 50 moles, light-colored skin, regular sun exposure without sunscreen, and/or a family history of melanoma are at increased risk for melanoma.

• • Normally, nevi are smaller than 6 mm in diameter, round, and smooth-surfaced, with distinct/round edges. They can be elevated or not; their color can be pink, tan, brown, or dark brown. Generally, persons with darker skin tones have darker moles and persons with lighter skin tone have lighter moles. See Figure 6.5 for examples of what is considered normal nevi.
  • Abnormal moles are often larger than 6 mm with variation in colors and asymmetrical with irregular borders. Note any atypical moles, including the location and description.

3. Inspect for skin integrity including whether the skin is intact. Look for the presence of ulcerations, erosions, contusions, or other damage that can disrupt the normal pattern of the skin. You will learn to recognize the signs of skin breakdown and who is at risk for impaired skin integrity. An important tool to assess skin integrity is the Braden Scale, which is commonly used in many health care settings and is especially useful for hospitalized clients and those with restricted mobility. 

• • Skin is normally intact with no lesions, ulcerations, erosions, and contusions. 
  • If you observe any areas where the skin is not intact, note the location and describe the area. Pressure injuries are classified into stages, as shown in Table 6.8. Figure 6.6 presents an example of staging.

4. Inspect skin for hygiene including your sense of smell. Look for areas that appear dirty, oily, or overly dry. Assess for areas of excessive dryness or moisture and smell the skin for any unpleasant odors which may indicate inadequate cleaning or infections.

5. Note the findings.

• • Normal findings might be documented as: “Skin integrity intact. Skin color consistent throughout with no variations. No lesions or rashes noted. Nevus on back examined. Located 2 inches distal to the scapula, left side. Symmetrical with even borders, tan colored, 3 mm in size, and no changes noted by the client. No pain or sensation reported. Image taken and included in the chart.”
  • Abnormal findings might be documented as: “Stage 1 pressure injury on thoracic spine 4 inches in length and 2 inches wide”

Activity: Check Your Understanding

References

Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1998). Predicting pressure ulcer risk: A multisite study of the predictive validity of the Braden Scale. Nursing Research, 47(5), 261-269.

Bergstrom, N., Braden, B., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210.

Braden, B. (2012). The Braden Scale for predicting pressure sore risk: Reflections after 25 years. Advances in Skin & Wound Care, 25(2), 61.

Open Resources for Nursing (n.d.). Chippewa Valley Technical College. https://wtcs.pressbooks.pub/nursingfundamentals/

Rigel, D., Friedman, R., Kopf, A., & Polsky, D. (2005). ABCDE–an evolving concept in the early detection of melanoma. Arch Dermatol, 141(8), 1032-1034.