Skin Assessment - Nursing Physical Assessment Tutorial | Lecturio Nursing

Key Concepts:

Integumentary system assessment, skin color abnormalities (cyanosis, erythema, jaundice), pressure ulcers, skin pigmentation, varicose veins, DVT (deep vein thrombosis), cellulitis, venous/arterial disease, skin consistency (moisture, temperature, texture, turgor), skin surface assessment (wounds, lesions, asymmetry, border irregularity, color variation, diameter change), nail assessment (color, texture, clubbing), drains/tubes/IV lines assessment (insertion site, drainage, infection signs), JP drain (Jackson-Pratt drain).

I. Integumentary System Assessment: General Appearance and Skin Color

• The integumentary system, the largest organ, is assessed for color, volume, consistency, and surface appearance, including nails.
• General Appearance: Assess if the patient is obese or emaciated, calculating Body Mass Index (BMI) for care planning.
  • Example: Emaciation may necessitate a nutrition consult.
• Skin Color:
  • Cyanosis: Bluish color in extremities (fingers, toes, lips, face) indicates insufficient oxygenation and is an emergency.
  • Erythema: Redness due to irritation or injury.
    • Critical Point: Erythema on pressure points (coccyx, shoulders, heels) may indicate early pressure ulcer development, requiring immediate assessment and intervention.
  • Pigmentation: Changes can result from birthmarks, radiation therapy, rosacea, or other diseases. Document and assess appropriately.
  • Jaundice: Yellowing of the skin due to bilirubin buildup. Common in newborns with immature bilirubin processing and patients with alcoholism or liver damage. May require special light treatment.

II. Skin Abnormalities: Varicose Veins, Swelling, and Ulcers

• Varicose Veins: Common in nurses, factory workers, and pregnant women due to prolonged standing. Generally benign but can cause discomfort and increase clotting risk due to blood pooling.
• Swelling: Unilateral leg swelling can indicate:
  • DVT (Deep Vein Thrombosis): Blood clot in the leg.
  • Cellulitis: Skin infection with inflammation.
  • Both require immediate attention and treatment by a healthcare provider.
• Skin Changes: Can result from irritation, medications, or diseases.
  • Venous Disease: Redness and irritation on shins, ankles, or calves.
  • Arterial Disease: Dark, purplish, shiny, and tough legs.
• Ulcers: Can be caused by venous or arterial issues, or pressure, especially on the heel. Painful, dangerous, and require prompt attention.

III. Skin Consistency: Moisture, Temperature, Texture, and Turgor

• Moisture: Assess for excess moisture or diaphoresis (sweating).
• Temperature:
  • Elevated Temperature: Hot skin around a surgical incision may indicate infection.
  • Decreased Temperature: Cold feet in patients with arterial disease indicate poor perfusion. Report to the healthcare provider.
• Texture: Note any unusual skin texture and determine if it's normal for the patient.
• Turgor: Assesses hydration status.
  • Procedure: Pinch skin on the chest wall. Rapid return indicates good hydration. Slow return suggests dehydration.
  • Note: Back of the hand is less reliable due to age-related skin laxity.

IV. Skin Surface Assessment: Wounds, Lesions, and Nails

• Surface Assessment: Check for wounds and lesions.
  • Lesion Assessment (ABCDE):
    • Asymmetry: Irregular shape.
    • Border: Irregular or poorly defined.
    • Color: Uneven or multiple colors.
    • Diameter: Larger than 6mm or increasing in size.
    • Evolution: Changing in size, shape, or color.
    • Encourage patients to follow up with a healthcare provider for suspicious lesions.
• Nail Assessment: Indicates nutritional status, infections, trauma, and oxygenation problems.
  • Purplish Color: May indicate trauma.
    • Example: Shutting finger in a car door.
  • Yellowing: May indicate nutritional or vitamin deficiency or fungal infection.
  • Clubbing: Raised, distorted nail bed indicates long-term oxygenation issues, common in COPD patients.
  • Brittle, Ridged, or Broken Nails: May indicate nutritional deficiencies or long-term disease.

V. Assessment of Drains, Tubes, and IV Lines

• Insertion Site: Check for signs of infection, cleanliness, and unusual discharge.
  • Signs of Infection: Redness, pus, or drainage around the insertion site.
  • Report any abnormalities immediately. May require removal of the drain, tube, or IV line.
• Maintenance:
  • Ensure no kinks in tubing.
  • Avoid pulling on tubing.
  • Apply suction if required by the equipment.
  • Example: Jackson-Pratt (JP) drain is a common surgical drain to collect excess fluid from an incision.

VI. Conclusion

A comprehensive integumentary assessment involves evaluating skin color, consistency, surface, and appendages like nails. Recognizing abnormalities such as cyanosis, erythema, jaundice, and changes in skin turgor, texture, and temperature is crucial for identifying underlying conditions and implementing timely interventions. Proper assessment and maintenance of drains, tubes, and IV lines are also essential to prevent complications and ensure patient safety.