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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
What are the factors that affect skin integrity?Skin is affected by both intrinsic and extrinsic factors. Intrinsic factors can include altered nutritional status, vascular disease issues, and diabetes. Extrinsic factors include falls, accidents, pressure, immobility, and surgical procedures.
What factors need to be checked and considered when assessing a wound?Wound Assessment. Type of wound- acute or chronic.. Aetiology- surgical, laceration, ulcer, burn, abrasion, traumatic, pressure injury, neoplastic.. Location and surrounding skin.. Tissue Loss.. Clinical appearance of the wound bed and stage of healing.. Measurement and dimensions.. Wound edge.. Exudate.. What should you look for when assessing the condition of the skin?A skin assessment in adults should take into account:. any pain or discomfort reported by the patient.. skin integrity in areas of pressure.. colour changes or discoloration.. variations in heat, firmness and moisture (for example because of incontinence, oedema, dry or inflamed skin).. What are risk factors for poor skin integrity?Friction, shear, moisture, pressure, and trauma are all causes of skin breakdown. These factors can work together or alone to damage and injure skin. Immobility, poor nutrition, incontinence, medications, hydration, impaired mental status, and loss of sensation are other culprits in skin breakdown.
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