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02.02 Integumentary (Skin) Assessment

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Overview

  1. When assessing  skin, you should inspect every inch of the patient’s skin
    1. Remove/lift gown
    2. Remove socks
    3. Look under dressings – unless contraindicated or have an order not to remove dressing

Nursing Points

General

  1. Integumentary assessments are often done simultaneously with other body systems
    1. More efficient
    2. Can observe/inspect skin while inspecting other aspects of that are
  2. Supplies needed
    1. Wound measurement tape/supplies
    2. Dressing supplies as needed

Assessment

    1. Inspect
      1. Color
        1. Should be consistent with ethnicity
        2. Jaundice, cyanosis, pallor, erythema – may indicate a disease process
        3. In darker-skinned patients, look at sclera, lips, and nail beds for color changes
      2. Moisture
        1. Diaphoresis may indicate fever, hypoglycemia, anxiety, or other disease process
      3. Wounds/lesions
        1. Color
        2. Drainage
        3. Size
          1. Length
          2. Width
          3. Depth
        4. Tunneling or undermining
        5. Location
        6. Raised
        7. Texture
        8. ABCDE mnemonic to assess moles
      4. Pressure areas
        1. Back of head
        2. Hips
        3. Sacrum
        4. Heels
        5. Shoulders
        6. Other bony prominences
      5. Edema
        1. If present, assess for pitting
        2. Note location and severity
        3. Can take circumference measurements
      6. Hair growth
        1. Present where it should be?
        2. Absent where it shouldn’t?
      7. Nails
        1. Color
        2. Shape
        3. Texture
    2. Palpate
      1. Edema – fluid accumulation under the skin
        1. Press finger or thumb into edema to assess for pitting
      2. Temperature – use the back of your hand to feel the skin
        1. Should be warm to touch, but not hot
        2. Cool or cold skin may indicate perfusion issues
      3. Turgor
        1. Pinch skin over clavicle – it should rebound almost immediately
        2. Tight?
          1. Can barely pinch
        3. Tenting?
          1. Skin tents for >3 seconds
      4. Moisture
      5. Tenderness
    3. Abnormal findings
      1. Color changes
        1. Hyperpigmentation
          1. Addison’s disease
        2. Hypopigmentation
          1. Vitiligo
        3. Erythema – redness
          1. Inflammation
        4. Cyanosis – bluish color
          1. Oxygenation issues
        5. Pallor – whitish color
          1. Perfusion issues
        6. Jaundice – yellowing of skin or eyes
          1. Liver failure
      2. Edema
        1. Pitting edema scale
          1. 1+ mild pitting (2mm, rebounds quickly)
          2. 2+ moderate pitting (4mm, rebounds in 3-4 seconds)
          3. 3+ severe (6mm, 10-15 seconds to rebound) – usually generalized throughout extremity
          4. 4+ extreme (8mm+, >20 seconds to rebound – sometimes minutes, generalized throughout extremity, may have perfusion issues)
        2. Dependent
          1. Found only on the lowest aspect (closest to the ground) of the body part
        3. Generalized (anasarca)
          1. Edema throughout body, usually non-pitting
      3. Absence of hair growth
        1. May indicate chronic venous insufficiency
      4. Lesions
        1. Macule
          1. A flat area of hyperpigmentation, usually less than 10mm.
        2. Patch
          1. A larger macule (>10mm)
        3. Papule
          1. A well-defined raised area with no visible fluid, usually less than 10 mm.
        4. Plaque
          1. A large papule or group of them, usually greater than 10 mm, or a large raised plateau-like lesion.
        5. Nodules
          1. Similar to a papule – raised area with no fluid – but is much deeper in the dermis
        6. Vesicles
          1. A small, well-defined raised area filled with fluid, usually <10mm.
          2. Also known as a blister
        7. Bulla
          1. A large vesicle, usually >10mm.
          2. Also known as a blister
        8. Ulcers
          1. Involve loss of the epidermis and some or all of the dermis
        9. Fissures
          1. A crack in the skin that is usually narrow but deep.
        10. Erosions
          1. Involve full loss of the epidermis in a defined area.
      5. Nail abnormalities
        1. Clubbing
          1. Hypoxia or hypoxemia
        2. Scoop-like nails
          1. Anemia
        3. Pale nail beds
          1. Perfusion issues
      6. Turgor
        1. Tight – may have swelling, edema, or venous insufficiency
        2. Tenting – dehydration

Nursing Concepts

  1. You may be able to defer detailed wound assessments to a WOCN (Wound-Ostomy-Continence Nurse) depending on your facility policy – but you should still ALWAYS at least LOOK at the wound
  2. Make note of abnormal findings in order to document with your assessment

Patient Education

  1. Importance and purpose of assessing ALL areas of skin
  2. Pressure ulcers/ Pressure injuries can develop in less than 2 hours – importance of turning/repositioning frequently

Reference Links

Study Tools

Video Transcript

When you’re doing a head to toe assessment, one of the most daunting components in the integumentary, or skin assessment. Here’s the reality – you HAVE to assess EVERY inch of your patient’s skin. You just have to. Now, usually, we’ll assess skin throughout our head to toe as we do other assessments on other parts of the body. But for the sake of this video, let’s walk you through a specific integumentary assessment.

First, always make sure you explain what you’re going to be doing to your patient. The last thing you want is to start lifting their gown without their permission. Start at the head and face and work your way down. You’re looking at the skin’s color – does it match their ethnicity, are there any pigmentation changes? Or do you notice any cyanosis, jaundice, or redness? Are there any wounds or lesions, is it moist or dry? When you get to the patient’s shoulders and chest, make sure you pinch the skin over their clavicle to check the turgor – you should see it rebound quickly. If you see tenting it might mean they’re dehydrated.

Then move on to the upper extremities, again looking for color, moisture, wounds or lesions, edema, feel the temperature of them – are they hot or cold? Look at their elbows and bony prominences and other pressure areas.

Then you want to lift their gown and assess their abdomen, look for scars from previous surgeries, any swelling. You also want to make note of things like freckles or moles.

Continue assessing the patient’s legs and lower extremities looking for the same things – color, temperature, moisture. You also want to make note of hair growth – is there hair where there should be hair? If you see dark discoloration and an absence of hair growth on the lower extremities, that could mean they’ve got some venous insufficiency. Especially if they’re also cold. And of course if you see any edema, make sure you check for pitting by pressing your finger or thumb into the swelling.
You also want to look at their fingernails and toenails – what color are they, are they shaped differently like clubbed or spoon-like? Remember – you HAVE to remove their socks!
Once you’ve gone head to toe on the front – you HAVE to turn them over and look at the back! This part gets missed SO much!
Work head to toe again, paying close attention to pressure areas like the back of the head, shoulder blades, sacrum, and hips – pressure ulcers can develop SUPER quickly! If at any point you find any lesions or wounds, make sure you get more detailed information like size, shape, color, drainage, and ask the patient how long it’s been there and if it’s painful.

Once you’ve finished your skin assessment, make sure you document any abnormal findings, dress any wounds as appropriate, and make sure the patient is comfortable.

Make sure you check out the outline attached to this lesson for more details on abnormal findings and for a list of what to assess in the integumentary system. Now, go out and be your best selves today. And, as always, happy nursing!

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