02.02 Integumentary (Skin) Assessment

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Skin Lesions (Cheat Sheet)
Macule and Patch (Image)
Papule and Plaque (Image)
Nodules (Image)
Vesicles and Bulla (Image)
Ulcers Fissures and Erosions (Image)
Layers of the Skin (Image)
Nursing Assessment (Book)

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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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