Skin Assessment 

Nursing Knowledge

Skin Assessment 

A nursing skin assessment is a foundational and comprehensive examination of a patient’s integumentary system. It involves inspecting and palpating the skin and its appendages to identify any abnormalities. A skin assessment is a valuable clinical tool, as the skin as the largest organ often mirrors underlying health conditions and offers insights into a patient’s overall well-being.
Last updated: December 4, 2023

Table of contents

What is done in a nursing skin assessment? 

In a skin assessment, a full-body skin exam can be performed by nurses to examine the client’s skin systematically: 

  • Inspection: color, lesions, rashes, ulcers
  • Palpation: temperature, moisture, turgor, edema/masses
  • Assess:
    • Wounds: size, surrounding skin, infection
    • Hair, nails: texture, distribution, pests like lice, nail clubbing/ridges

What is skin turgor? 

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. 

Skin assessment tools

Standardized tools or instruments can help guide skin assessment procedures, for example: 

  • ABCDE is a skin assessment tool and mnemonic used to evaluate skin lesions for skin cancer:
    • Asymmetry (of moles/lesions)
    • Border (irregular, ragged, blurred edges)
    • Color (inconsistent)
    • Diameter (larger than 6 mm, although melanomas can be smaller)
    • Evolving (changes over time)
  • Guided checklists
  • Scoring systems for pressure injury stages
  • Braden scale (predictive tool for pressure injury risk) 

Skin assessment documentation 

The documentation of skin lesions should include: 

  • Lesion type
  • Lesion configuration
  • Location
  • Distribution
  • Color
  • Measurements 

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: 

  • Circinate
  • Arciform
  • Linear
  • Serpiginous
  • Annular
  • Target
  • Gyrate
  • Zosteriform

The distribution of lesions can be categorized as follows: 

  • Localized
  • Generalized
  • Symmetric
  • Asymmetric
  • Discrete
  • Grouped
  • Coalescing
  • Cleavage plane

Common skin lesions 

  • Macule: localized change in skin color, < 1 cm in diameter 
  • Papule: solid, elevated lesion, < 0.5 cm in diameter 
  • Plaque: solid, elevated lesion, > 0.5 cm in diameter 
  • Nodule: solid, elevated, extends into dermis or subcutaneous tissue, 0.5–2 cm in diameter 
  • Tumor: same as nodule, but > 2 cm in diameter 
  • Wheal: localized edema of epidermis causing irregular elevation
  • Vesicle: elevated mass containing serous fluid, < 0.5 cm 
  • Bullae: same as vesicle, only > 0.5 cm 
  • Pustule: vesicle or bullae that become filled with pus
  • Cyst: encapsulated fluid-filled or semi-solid mass

Nursing skin assessment examples

PapuleElevated nevi, seborrheic keratosis
PlaquePsoriasis, eczema
NoduleLipoma, melanoma
TumorBreast carcinoma
WhealInsect bite, hive, angioedema
VesicleHerpes simplex, chicken pox
BullaeContact dermatitis, second-degree burns
PustuleAcne, impetigo, furuncle, folliculitis
CystSebaceous cyst, epidermoid cyst

Important skin assessment findings

The following are important skin assessment findings that are examples of findings that require monitoring for other conditions or diagnoses: 

  • Very pale skin may suggest anemia 
  • Cyanosis may suggest poor oxygenation
  • Jaundice may suggest liver dysfunction
  • Erythema can be from inflammation or infection
  • Moles can indicate melanoma
  • Rashes can be indicative of allergies 
  • Heat can be indicative of inflammation or infection
  • Poor skin turgor can hint to dehydration
  • Bruising can suggest clotting disorders or physical abuse


Skin Assessment 

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An overview of how to describe skin lesions

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