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Nursing Knowledge
In a skin assessment, a full-body skin exam can be performed by nurses to examine the client’s skin systematically:
Skin turgor refers to the skin’s elasticity and how well it returns to its original shape. It gives insight into the state of the skin’s hydration. It can be assessed by pinching a fold of skin, as on the back of the hand, and then releasing it. If skin turgor is good, the skin quickly returns to its original position. If skin turgor is poor, the skin takes longer to reshape or remains elevated.
Standardized tools or instruments can help guide skin assessment procedures, for example:
The documentation of skin lesions should include:
A skin assessment form may be used to facilitate documentation.
Using standardized terminology when describing skin lesions helps communication and efficiency in the healthcare team, and minimizes the risk of misinterpretations.
The configuration of lesions can be described as follows:
The distribution of lesions can be categorized as follows:
| Lesion | Examples |
| Macule | Freckle |
| Papule | Elevated nevi, seborrheic keratosis |
| Plaque | Psoriasis, eczema |
| Nodule | Lipoma, melanoma |
| Tumor | Breast carcinoma |
| Wheal | Insect bite, hive, angioedema |
| Vesicle | Herpes simplex, chicken pox |
| Bullae | Contact dermatitis, second-degree burns |
| Pustule | Acne, impetigo, furuncle, folliculitis |
| Cyst | Sebaceous cyst, epidermoid cyst |
The following are important skin assessment findings that are examples of findings that require monitoring for other conditions or diagnoses:
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