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Week 9 Assessment of Integumentary System (Skin)
Learning Objectives1. Describe and list factors that affect tissue integrity. 2. Explain common physical assessment procedures used to evaluate tissue integrity of patients across the lifespan. 3. Identify priority tissue integrity assessment findings. 4. Differentiate normal tissue integrity assessment findings from abnormal findings. 5. Explain the process for assessment of tissue integrity.
Why is this a system? What does it do for us?
The skin is the body's largestorgan, covering the entire body.
Our skin serves as a protective shield against: • Heat • Light • Injury • Infection
Skin also: • Regulates body temperature • Stores water and fat • Is a sensory organ • Prevents water loss • Prevents entry of bacteria
Inspection of the Skin: Nurses conduct an examination of the skin as part of a routine assessment, during regular care, and as needed.
During a bed bath is a good time fully assess the patients skin.
Remove all barriers unless contraindicated: i.e. wound dressing
Assess and Document: • Location • size • objective description • skin temperature
A scar can indicate a healed surgical wound or injury.The nurse should make note of this.
Everted Umbilicus: Indicates increased pressure in the abdomen
Palpation of the skin:Does it feel dry, moist, rough, smooth, bumpy, etc?Do you feel swelling, edema, coolness, heat, is the area warmer than surrounding skin?
Unhealthy Skin Before and after Meth
Basic Assessment Interview Questions • Have you ever had any skin problems? • If yes, was this acute and/or chronic? • Do you have any bruises, sores, ulcers or • rashes on your body and are they slow to • heal? • Do you have any skin pain, burning or itching?
More Interview Questions • Do you sunbathe or have a history of sunbathing? • Do you work outdoors? • How does your skin react to sun exposure? • How do you care for your skin? • Sensitivities or allergies? • Tattoos and/or piercings?
Considerations as the nurse… • Is the patient nutritionally challenged? • Is the patient immobile? • Does the skin appear paper-like or fragile?
1. Outer Skin Layer2. Middle Skin Layer3. Deep Skin Layer4. First Degree Burn5. Second Degree Burn6. Third Degree Burn
Poison Ivy is an allergic reaction.(Oily sap called urushiol triggers an allergic reaction when it comes into contact with skin, resulting in an itchy rash, which can appear within hours of exposure or up to several days later.)
Venous Stasis Ulcers: The result of venous blood collecting and stagnating in the lower leg (Inadequate venous return).
Necrotic ToesWhat causes this? Decreased/impaired tissue perfusion.
Diabetics are at high risk for slow healing wounds due to vascular changes leading to arteriosclerosis (thickening, loss of elasticity, and calcification of arterial walls).
Pressure Ulcer: (decubitus ulcer) This is preventable by repositioning the patient every two hours.
Age Spots:(Liver Spots) Part of the skin’s normal aging process. Appear asflat gray, brown or black spots. They vary in size and usually appear on the face, hands, shoulders and arms; areas most exposed to the sun.
Laceration:Tissues torn apart, open wound; edges often jagged
Puncture or Penetrating: Penetration of skin and underlying tissues; open wound
Wound Measurement Guide: Assess if the wound is getting larger, smaller, healing, etc.
Abscess: A swollen area within body tissue, containing an accumulation of pus.
