Nursing Assessment of the Integumentary System

00:01 Now let's move on to one of the biggest organs of the patient's body, which is our integumentary system. Now, as we move through our head to toe assessment, we're going to be looking at color, volume, consistency of the patient's skin, surface appearance, and even include the nails because believe it or not, that can tell us a lot.

00:21 So when we're talking about looking at our patient's general appearance, we need to look at are they obese, are they emaciated.

00:29 We need to assess someone's body mass index.

00:32 Believe it or not, that can actually give us a lot of information and care planning.

00:36 Now it's important to note, for example, if they're emaciated, this could mean that we've got to have a nutrition consult to assess the patient's needs.

00:44 Now, knowing this can help us better plan for our care and also give appropriate equipment for patient support.

00:52 Now, don't forget when we're talking about a skin assessment, color is an easy indicator that something's going on. So don't forget if you see cyanosis or a bluish color in any of the patient's extremities.

01:05 This could mean that there's not enough oxygenation to the patient's fingers, their toes or lips or face, for example.

01:13 And this is an emergency.

01:15 So next you may see erythema or a really fancy Word which is an area of redness. Now this can happen for a couple of different reasons.

01:24 This can be from irritation.

01:25 It could be from injury.

01:27 Now here is a really important point to note.

01:30 If you see erythema on any pressure points or bony prominences such as the coccyx, back of the shoulders, maybe the, the heels, for example, and you see this redness, that could be an early indicator that the patient may have a pressure ulcer that's starting to grow. If that's the case, we've got to assess and intervene early.

01:52 Now next pigmentation.

01:54 There can be changes that can be from birthmarks, radiation therapy, rosacea or other disease processes.

02:01 So just make sure you note this and assess and document appropriately.

02:06 Now, here's an important point on skin color to make sure that you keep in mind as a nurse.

02:11 So you may see something called jaundice, kind of like you see in this image here.

02:16 You see on one side the patient's normal skin color.

02:19 And on the other side it's more of a yellow.

02:21 Now this is a build up of bilirubin.

02:24 And just if you recall you may see this really often in babies because they're not quite mature enough to get rid of that bilirubin on their own.

02:33 So sometimes you may see a special light to help with this.

02:36 And also in your patients with alcoholism or severe history, you may see jaundice because of liver damage.

02:44 So some additional skin abnormalities that we want to consider is varicose veins.

02:50 Now these can be pretty common in patients with actually nurses that stand on their feet a lot,factory workers, even patients that are pregnant.

02:59 So one thing to note about varicose veins these are usually pretty benign.

03:04 They're not usually a life threatening thing.

03:07 But However, they can cause some discomfort.

03:10 So the issue with these is that blood can pool in these areas, and they can put them at a little bit more increased risk for clotting.

03:17 Now speaking of clots, let's look at this image of swelling.

03:21 So you see how the one leg is really large.

03:25 Now you see there's unilateral largeness and swelling in one leg.

03:30 This can mean a couple of things.

03:31 The patient may have what we call a DVT or a deep vein thrombosis, a blood clot in the patient's leg. Or it could be that there's a skin infection that got really infected and inflamed.

03:43 And we call this cellulitis.

03:45 Both of these are really important to note.

03:48 And that needs quick treatment by the provider.

03:51 Now next there can be some various skin changes.

03:54 This can be from irritation, medications or diseases.

03:59 So one thing to note if you're talking about a patient with venous disease they may have some redness, some irritation on the shins or around their ankles or around their calves, for example.

04:11 Now, some patients with arterial disease, you'll kind of see the legs get, dark purplish, shiny kind of tough.

04:19 That is a good indicator on assessment that this is arterial disease in your patient.

04:24 And lastly there can be ulcers which are really a big deal.

04:28 This can actually be from venous issues or arterial issues or just pressure ulcers especially at the heel.

04:36 Now these can be very painful.

04:38 They can be dangerous and they need special and prompt attention.

04:43 Some additional considerations when we're talking about assessing a patient's skin is look at some consistency factors.

04:50 So one of those is moisture.

04:52 If there's excess moisture or the patient is sweating or what we call diaphoresis.

04:57 Next is temperature.

04:59 So something to really note that if there's a particular area, especially like a surgical incision and we touch the patient's skin and it's really hot around those areas, that could be something to note and could indicate infection.

05:14 Now just note on the opposite end that let's say you're assessing a patient's feet for example and they have arterial disease meaning lack of blood flow or limited blood flow to their legs. Now, if we touch or assess the patient's lower legs and feet and it's really abnormally cold, this could mean that there's poor perfusion.

05:35 And we also want to note this to the health care provider.

05:38 So texture's a little bit different.

05:41 Some patients have different textures to their skin.

05:43 But you want to talk with your patient and see if this is normal for them or something that needs to be addressed.

05:50 And lastly turgor is also an important consideration when we're talking about hydration status of our patient.

05:57 Now you see here the image is at the back of the patient's hand.

06:01 Now as you can imagine, over time, especially with aging, the skin behind the hand can get kind of loose. So ideally it's best to assess this by the patient's chest wall grabbing the patient's and pinching up a little skin pulling it back and releasing.

06:16 So this should snap back rather quickly.

06:19 And this means that there's good hydration and a good hydration status for your patient.

06:24 But if you pinch up the skin and then you let it go and it's kind of slow to return to normal, that may mean that the patient is severely dehydrated.

06:33 And we need to address this.

06:36 So another thing to keep in mind when we're talking about the skin and we're assessing this is especially looking at the surface.

06:43 Are there any wounds? Are there any lesions? So if you take a look at this image, if you see any sort of asymmetry to the lesion, if it's an abnormal color, if the diameter has changed, if the border is oddly shaped, this is something that you may encourage the the actual patient to follow up with a health care provider to see if this is a cancerous lesion or something that's benign.

07:10 So next let's talk about nails.

07:12 So you may not think that this is something that's really that important, but it actually can tell us a lot about the nutritional status of the patient if they've got infections or had traumas, or even if there's long-term oxygenation problems with the patient.

07:28 So if you take a look at this image, you see this purplish color in the nail.

07:32 That usually could mean like trauma.

07:34 For example, I know one of my nails turned purple when I accidentally shut my nail in the car door, for example. So next is yellowing.

07:43 So this is actually important because this can mean that your patient has nutritional or a vitamin deficiency. Or it could even indicate that there's a fungal infection that needs to be treated.

07:55 Now next in the middle of this slide you see what we call clubbing.

07:59 So you see how if you look at the nail it's normal.

08:02 It's pretty flat.

08:04 But if you see this distorted kind of a raised nail bed we call that clubbing.

08:09 And that's usually indicates that the patient has had long-term oxygenation issues. This is commonly going to be seen with our patients who have COPD.

08:22 Now next looking at texture with our patient.

08:24 Now if you look at the patient's nails and they're brittle and like really oh ridges and bumpy or broken this can mean that there's also nutritional deficiencies or long-term disease. So moving along with our head-to-toe assessment, as you can imagine, there may be various drains or tubes or IV lines that must be assessed by us as nursing.

08:48 So it's really important to check the insertion or that surgical site.

08:53 So we've got to look for signs of infection, the cleanliness around that site, any odd discharge like you see here on this image.

09:03 Is there any odd discharge on the dressing? Is there any redness around the insertion site? Do you see weird pus or drainage coming out? All of this is especially important with any sort of drain tube or IV line, and you need to report that immediately.

09:19 So sometimes you've got to communicate with your health care provider.

09:23 Sometimes this indicates that that drain tube or IV line must be removed.

09:30 And next, when you're talking about assessing any sort of drains or tubes, for example, it's really important that we maintain those appropriately.

09:39 Now what I mean by this is if you look in this image here, you see a very common surgical drain that usually comes from an incision.

09:48 So this is going to help collect any excess drainage or blood.

09:51 Now the one you see in this image is very common.

09:54 And we call this a JP drain or a Jackson Pratt drain.

09:59 Now when you're looking at maintaining drains or tubes, any drains such as this, you want to make sure there's no kinks in the tubing, it's not being pulled on.

10:08 Many times this is collecting excess fluid from that specific incision.

10:13 Also, depending on the equipment there may be a certain mechanism for suction.

10:18 So make sure this is applied if appropriate.