Assessment Technique
Inspect all skin surfaces (need assistance for back). Lighting: natural or bright. Use ABCDE for moles: Asymmetry, Border irregular, Color varied, Diameter >6 mm, Evolving. Assess: color, temperature, turgor, moisture, lesions, hair distribution, nails. Pressure points: sacrum, heels, hips, elbows, ears. Document location, size, characteristics.
Common Findings
Normal: warm, dry, intact, good turgor (pinch returns quickly). Abnormal: pallor, cyanosis, jaundice, erythema, ecchymosis, petechiae, purpura, telangiectasia. Lesions: primary (macule, papule, vesicle, bulla, pustule, nodule, tumor, wheal), secondary (scale, crust, erosion, ulcer, fissure, atrophy). Skin tears, pressure injuries, wounds, rashes.
Documentation
Document: location (use body diagram), size (measure in cm), shape, color, borders, elevation, exudate, surrounding skin, pain, onset, progression. Use standardized terminology. Photograph per policy. For pressure injuries: stage, size, exudate, tissue type. For skin tears: STAR classification. Track changes over time. Report new or worsening findings.
Important Notes
- Use ABCDE for melanoma screening: Asymmetry, Border irregular, Color varied, Diameter >6 mm, Evolving — any positive warrants dermatology referral.
- Assess ALL pressure points during skin assessment: sacrum, heels, hips, elbows, occiput, ears — missed areas lead to missed pressure injuries.
Clinical Tips
- Document skin findings using specific terminology: macule (flat, <1 cm), papule (raised, <1 cm), vesicle (fluid-filled, <1 cm), bulla (fluid-filled, >1 cm).
- Skin turgor assessed by pinching — tenting (slow return) indicates dehydration.
Summary
Skin assessment requires systematic inspection of all surfaces, using standardized terminology, and documenting findings accurately with body diagrams and measurements.
