02.02 Integumentary (Skin) Assessment

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. 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