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.
The lecture Nursing Assessment of the Integumentary System by Samantha Rhea, MSN, RN is from the course Assessment of the Integumentary System (Nursing).
What is considered a medical emergency?
What can be an early indicator for a pressure ulcer?
How does the nurse assess for skin turgor?
What can yellow nails potentially indicate? Select all that apply.
The student nurse is discussing integumentary system assessments with their instructor. Which statement of the student nurse indicates an understanding of the skill? Select all that apply.
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