Welcome to this video on skin assessment! The skin is the largest organ of the body and has many areas involved in its assessment. In this video, I’ll be focusing on a general assessment of the skin as well as how to implement measures to maintain skin integrity and prevent skin breakdown. Show
Diseases of the skin may be local, or they may be caused by an underlying systemic problem. In order to perform a complete and accurate assessment, the nurse needs to collect data about current symptoms, the patient’s past and family history, and health and lifestyle practices. When looking at current symptoms, ask the patient:
Guideline for collecting the needed information about symptoms:
When assessing past health history, ask the patient:
When looking at the family history, ask the patient:
Some skin conditions tend to be hereditary or contagious, so it is beneficial to know what the patient has been exposed to and what runs in their family. Lifestyle and health practices play a big role in the assessment of skin. Ask the patient:
The physical assessment of the skin involves inspection and palpation and may reveal local or systemic problems in the patient. Inspection involves looking at the following:
When palpating the skin, it is important to note:
A very common skin problem you will encounter as a nurse is the pressure ulcer, also known as a bedsore. Pressure ulcers are localized injuries to the skin and underlying tissue that nearly always develop in areas where there are bones right under the skin. This includes the heels, ankles, tailbone, hips, elbows, shoulder blades, ears, and back of the head. If body weight is continually putting pressure in places where a person is sitting or lying for a long time, not enough blood can get through to provide oxygen and nutrients. The skin becomes thinner, and over time it gradually dies, creating an open wound. Risk factors for skin breakdown leading to pressure ulcers include poor circulation, poor hygiene, infrequent position changes, infection, dermatitis, or traumatic wounds. Pressure ulcers can lead to sepsis and even death, and they are much easier to prevent than to treat. As a nurse, it is extremely important to assess the patient’s skin adequately and carry out preventative measures. For an initial assessment of the potential to develop a pressure ulcer, use the Braden Scale. This assessment tool measures:
The nurses’ responsibility for assessing and preventing pressure ulcers includes the following:
If the patient is bed or chair-bound:
If a patient has to sit or lie down without moving for a long time—even if just for a few days—it is important to reduce pressure on the parts of the body that are most at risk. Remember, document everything you do, because in the medical-legal world, if you didn’t document it, you didn’t do it. Thank you for watching this video tutorial on skin assessment! Which action made by the nurse during palpation of a patients skin would require follow up from the charge nurse quizlet?which action made by the nurse during palpation of a patient's skin would require follow-up from the charge nurse? c. checking thickness with the palmar surface of hand. the nurse would require follow up from the charge nurse if he or she checked turgor and elasticity by using the dorsum of the hand.
Which action made by the nurse during palpation of a patient's skin would require follow up?Terms in this set (72) A nurse is examining a patient's skin using palpation. Which action made by the nurse needs correction? RATIONALE: The nurse should check Skin turgor and elasticity by grasping the skin with fingertips, not by using the dorsum of the hand.
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.
When assessing a patient's skin What does the nurse need to know?This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present.
|