00:01
Now, let's move on
to one of the biggest organs
of the patient's body,
which is our integumentary system.
00:07
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 we're talking about looking at
our patients general appearance.
00:24
We need to look at: Are they obese?
Are they emaciated?
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.
00:55
Color is an easy indicator
that something's going on.
00:59
So don't forget,
if you see a cyanosis
or a bluish color in
any of the patient's extremities,
this can mean that
there's not enough oxygenation
to the patient's
fingers, their toes,
or lips or face, for example.
And this is an emergency.
01:14
So next,
you may see erythema
or a really fancy word,
which is an area of redness.
01:21
Now, this can happen for a
couple of different reasons.
01:24
This can be from irritation,
it can 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 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.
01:48
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 birthmark, radiation therapy,
rosacea
or other disease processes.
02:01
So just make sure
you note this and assess
and document appropriately.
02:05
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,
and on the other side,
it's more of a yellow.
02:21
Now this is a buildup 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.
02:41
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
uncommon in patients with, oh,
actually nurses that stain 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,
but however they can
cause some discomfort.
03:10
So the issue with these is that
blood can pull 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.
03:29
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,
and we call this cellulitis.
03:45
Both of these are
really important to note
and then these 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,
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, arterial issues,
or just pressure ulcers,
especially at the heel.
04:36
Now, these can be very painful.
They can be dangerous.
04:39
And they need special
and prompt attention.
04:43
Some additional considerations
when we're talking about
assessing a patient's skin
is looking at some
consistency factors.
04:50
So one of those is moisture
if there's excess moisture
or the patient is sweating
or what we call diaphoresis.
04:58
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.
05:10
That could be something to know
and could indicate infection.
05:14
Now, just note on the opposite end,
that let's say you're assessing
a patient, feet for example.
05:20
And they have arterial disease,
meaning lack of blood flow or
limited blood flow to their legs.
05:26
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
is a little bit different.
05:40
Some patients have different
textures to their skin,
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 overtime,
especially with aging,
the skin behind the hand
can get kind of loose.
06:07
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,
and we need to address this.
06:35
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 actual patient to follow up
with a healthcare 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.
07:16
But it actually can tell us a lot
about the nutritional status
of the patient
if they've gotten 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,
that usually could mean like
trauma, for example.
07:35
I know one of my nails turn purple
when I accidentally shut my nail
on the car door, for example.
07:41
So next is yellowing.
07:43
So this is actually important
because this can mean
that your patient has nutritional
or a vitamin deficiency.
07:49
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, it's pretty flat.
08:04
But if you see this distorted
kind of a raised nail bed,
we call that clubbing
and that's usually indicates
that the patient has had
long-term oxygenation issues.
08:16
This is commonly going to be seen
with our patients who have COPD.
08:21
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 ridges
and bumpy or broken,
this can mean that there's
also nutritional deficiencies
or long-term disease.
08:38
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
in the cleanliness
around that site,
any odd discharger like
you see here on this image,
is there any odd
discharge on the dressing?
Is there any redness
around the insertion site?
You see weird pus or drainage
coming out.
09:11
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 healthcare provider.
09:23
Sometimes this indicates that
that drain, tube, or IV line
must be removed.
09:31
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 gonna help collect
any excess drainage or blood.
09:52
Now, the one you see in
this image is very common,
and we call this a JP drain
or a Jackson-Pratt drain.
09:58
Now, when you're looking at
maintaining drains or tubes,
any drain such as this,
you want to make sure
there's no kinks in the tubing
is not being pulled on.
10:09
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.