Presentation on theme: "Week 9 Assessment of Integumentary System (Skin)."— Presentation transcript:
Week 9 Assessment of Integumentary System (Skin)
Learning Objectives 1. 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 largest organ, 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
Location size objective description skin temperature Assess and Document:
Also inspect and document any scars reported or noted.
A scar can indicate a healed surgical wound or injury. The nurse should make note of this.
Everted: Turned inside out; turned outward
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?
Skin should feel warm and dry with good color; not pale.
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?
Sun bathing and sunburn is considered a risk
Sunburn Blisters and Damaged Peeling Skin
1. Outer Skin Layer 2. Middle Skin Layer 3. Deep Skin Layer 4. First Degree Burn 5. Second Degree Burn 6. 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.)
Black henna tattoo reaction; scarring
Venous Stasis Ulcers: The result of venous blood collecting and stagnating in the lower leg (Inadequate venous return).
Necrotic Toes What 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).
Odor: Does the wound site have an odor?
Pressure Ulcer: (decubitus ulcer) This is preventable by repositioning the patient every two hours.
Varicella Rash (Chicken Pox)
Dry, Scaly Skin
Age Spots: (Liver Spots)
Age Spots: (Liver Spots) Part of the skin’s normal aging process. Appear as flat 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.
Contusions: Bleeding under or within layers of skin
Abrasion: Surface scrape, open wound
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.
Candida: Yeast/fungal infection
Skin breakdown under breasts: Skin must be kept clean and dry.
Port-Wine Stain Birthmark
Infants and children have sensitive skin… The younger the more sensitive the skin is Protect from sunburn Protect from rashes and irritation
Mongolian Spot Birthmark: A dense collections of melanocytes (not a bruise)
Older adults have sensitive skin: Skin changes associated with aging include less elasticity, decreased subcutaneous tissue. These factors put them at increased risk for tears, pressure ulcers, and skin breakdown.
Aging skin characteristics include decreased collagen, elasticity, tone.
Elderly skin is fragile, paper- thin, and tears easily.
Nursing Goals Include: Frequent and thorough skin assessment and interventions Promote wound healing Prevent skin breakdown and/or additional wounds
Injury to skin, and breaks in the skin put the patient at risk for what kinds of problems? Infection at the site, also systemic infection Loss of fluid Burns, internal injury, temperature regulation problems (Severe sunburn: fever and chills)
Bowel Sounds: When bowel sounds are hypoactive and not easily heard, you must listen for 5 minutes to each quadrant before deciding that bowel sounds are absent. True or False?
Ask the patient what time of day they normally move their bowels. (We attempt to work with the time schedule they are used to; not have them adjust to the facility’s time schedule.)
Passing gas indicates bowel motility and passing gas is taking place.