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Now that we have reviewed the anatomy of the integumentary system and common integumentary conditions, let’s review the components of an integumentary assessment. The standard for documentation of skin assessment is within 24 hours of admission to inpatient care. Skin assessment should also be ongoing in inpatient and long-term care.[1] A routine integumentary assessment by a registered nurse in an inpatient care setting typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill.[2] Subjective AssessmentBegin the assessment by asking focused interview questions regarding the integumentary system. Itching is the most frequent complaint related to the integumentary system. See Table 14.4a for sample interview questions. Table 14.4a Focused Interview Questions for the Integumentary System
Objective AssessmentThere are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown. Certain body areas require particular observation because they are more prone to pressure injuries, such as bony prominences, skin folds, perineum, between digits of the hands and feet, and under any medical device that can be removed during routine daily care.[4] InspectionColorInspect the color of the patient’s skin and compare findings to what is expected for their skin tone. Note a change in color such as (paleness), (blueness), (yellowness), or (redness). Note if there is any bruising () present. ScalpIf the patient reports itching of the scalp, inspect the scalp for lice and/or nits. Lesions and Skin BreakdownNote any lesions, skin breakdown, or unusual findings, such as rashes, petechiae, unusual moles, or burns. Be aware that unusual patterns of bruising or burns can be signs of abuse that warrant further investigation and reporting according to agency policy and state regulations. AuscultationAuscultation does not occur during a focused integumentary exam. PalpationPalpation of the skin includes assessing temperature, moisture, texture, skin turgor, capillary refill, and edema. If erythema or rashes are present, it is helpful to apply pressure with a gloved finger to further assess for (whitening with pressure). Temperature, Moisture, and TextureFever, decreased perfusion of the extremities, and local inflammation in tissues can cause changes in skin temperature. For example, a fever can cause a patient’s skin to feel warm and sweaty (diaphoretic). Decreased perfusion of the extremities can cause the patient’s hands and feet to feel cool, whereas local tissue infection or inflammation can make the localized area feel warmer than the surrounding skin. Research has shown that experienced practitioners can palpate skin temperature accurately and detect differences as small as 1 to 2 degrees Celsius. For accurate palpation of skin temperature, do not hold anything warm or cold in your hands for several minutes prior to palpation. Use the palmar surface of your dominant hand to assess temperature.[5] While assessing skin temperature, also assess if the skin feels dry or moist and the texture of the skin. Skin that appears or feels sweaty is referred to as being . Capillary RefillThe capillary refill test is a test done on the nail beds to monitor perfusion, the amount of blood flow to tissue. Pressure is applied to a fingernail or toenail until it turns white, indicating that the blood has been forced from the tissue under the nail. This whiteness is called blanching. Once the tissue has blanched, remove pressure. Capillary refill is defined as the time it takes for color to return to the tissue after pressure has been removed that caused blanching. If there is sufficient blood flow to the area, a pink color should return within 2 seconds after the pressure is removed. [6] Skin TurgorSkin turgor may be included when assessing a patient’s hydration status, but research has shown it is not a good indicator. is the skin’s elasticity. Its ability to change shape and return to normal may be decreased when the patient is dehydrated. To check for skin turgor, gently grasp skin on the patient’s lower arm between two fingers so that it is tented upwards, and then release. Skin with normal turgor snaps rapidly back to its normal position, but skin with poor turgor takes additional time to return to its normal position.[8] Skin turgor is not a reliable method to assess for dehydration in older adults because they have decreased skin elasticity, so other assessments for dehydration should be included.[9] EdemaIf edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema. See Figure 14.22[10] for an image demonstrating pitting edema. If pitting edema is present, document the depth of the indention and how long it takes for the skin to rebound back to its original position. The indentation and time required to rebound to the original position are graded on a scale from 1 to 4, where 1+ indicates a barely detectable depression with immediate rebound, and 4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound. See Figure 14.23[11] for an illustration of grading edema. Figure 14.22 Assessing Lower Extremity EdemaFigure 14.23 Grading of EdemaLife Span ConsiderationsOlder AdultsOlder adults have several changes associated with aging that are apparent during assessment of the integumentary system. They often have cardiac and circulatory system conditions that cause decreased perfusion, resulting in cool hands and feet. They have decreased elasticity and fragile skin that often tears more easily. The blood vessels of the dermis become more fragile, leading to bruising and bleeding under the skin. The subcutaneous fat layer thins, so it has less insulation and padding and reduced ability to maintain body temperature. Growths such as skin tags, rough patches (keratoses), skin cancers, and other lesions are more common. Older adults may also be less able to sense touch, pressure, vibration, heat, and cold.[12] When completing an integumentary assessment it is important to distinguish between expected and unexpected assessment findings. Please review Table 14.4b to review common expected and unexpected integumentary findings. Table 14.4b Expected Versus Unexpected Findings on integumentary Assessment
Which technique would the nurse use to assess the elasticity of the patients skin?Light palpation
Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
How does the nurse assess the elasticity of the skin in a patient thought to have dehydration?They main way to test skin turgor is to lightly pinch your skin, usually on your arm or abdomen. If it takes longer than usual for the skin to bounce back, it could be a sign of dehydration. However, this method isn't very precise. With age, your skin loses elasticity, causing poor skin turgor.
Which techniques will the nurse use to perform a physical examination of a patient's skin quizlet?Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination. Palpation refers to assessing by touch. Percussion involves assessment by tapping the skin with the fingertips to vibrate underlying tissues and organs.
Which method should the nurse use when assessing skin turgor of the patient?◂Assess skin turgor by gently pinching a fold of skin between your thumb and forefinger. The skin you select, such as below the clavicle or on the abdomen, sternum, or forearm, should feel resilient, move easily, and quickly return to its original position when released after a few seconds.
What is the correct sequence in assessment technique used to assess the skin quizlet?ANS: Warm the hands first before touching the patient., Start with light palpation to detect surface characteristics., Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps., Identify any tender areas, and palpate them last.
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