Now, let's move on to one of the biggest organs
of the patient's body,
which is our integumentary system.
Now, as we move through our head to toe assessment,
we're going to be looking at color, volume
consistency of the patient's skin,
surface appearance and even include the nails
because believe it or not, that can tell us a lot.
So we're talking about looking at our patients general appearance.
We need to look at: Are they obese? Are they emaciated?
We need to assess someone's body mass index.
Believe it or not, that can actually give us
a lot of information and care planning.
Now, it's important to note for example,
if they're emaciated?
This could mean that we've got to have a nutrition consult
to assess the patient's needs.
Now, knowing this can help us better plan for our care,
and also give appropriate equipment for patient support.
Now, don't forget when we're talking about a skin assessment.
Color is an easy indicator that something's going on.
So don't forget, if you see a cyanosis
or a bluish color in any of the patient's extremities,
this can mean that there's not enough oxygenation
to the patient's fingers, their toes,
or lips or face, for example. And this is an emergency.
So next, you may see erythema
or a really fancy word, which is an area of redness.
Now, this can happen for a couple of different reasons.
This can be from irritation, it can be from injury.
Now here is a really important point to note.
If you see erythema on any pressure points,
or bony prominences, such as the coccyx,
back of the shoulders, maybe the heels, for example,
and you see this redness,
that could be an early indicator
that the patient may have a pressure ulcer
that's starting to grow.
If that's the case, we've got to assess and intervene early.
Now, next, pigmentation.
There can be changes that can be from birthmark, radiation therapy,
rosacea or other disease processes.
So just make sure you note this and assess
and document appropriately.
Now here's an important point on skin color
to make sure that you keep in mind as a nurse.
So you may see something called jaundice,
kind of like you see in this image here.
You see on one side the patient's normal skin color,
and on the other side, it's more of a yellow.
Now this is a buildup of bilirubin.
And just if you recall, you may see this really often in babies
because they're not quite mature enough
to get rid of that bilirubin on their own.
So sometimes you may see a special light to help with this.
And also in your patients with alcoholism or severe history.
You may see jaundice because of liver damage.
So some additional skin abnormalities
that we want to consider is varicose veins.
Now, these can be pretty uncommon in patients with, oh,
actually nurses that stain on their feet a lot, factory workers,
even patients that are pregnant.
So one thing to note about varicose veins,
these are usually pretty benign.
They're not usually a life threatening thing,
but however they can cause some discomfort.
So the issue with these is that blood can pull in these areas
and they can put them at a little bit more
increased risk for clotting.
Now, speaking of clots,
let's look at this image of swelling.
So you see how the one leg is really large.
Now, you see there's unilateral largeness and swelling in one leg.
This can mean a couple of things.
The patient may have what we call a DVT,
or a deep vein thrombosis, a blood clot in the patient's leg,
or it could be that there's a skin infection
that got really infected and inflamed,
and we call this cellulitis.
Both of these are really important to note
and then these quick treatment by the provider.
Now next, there can be some various skin changes.
This can be from irritation, medications, or diseases.
So one thing to note,
if you're talking about a patient with venous disease,
they may have some redness, some irritation on the shins
or around their ankles, or around their calves, for example.
Now, some patients with arterial disease,
you'll kind of see the legs get
dark purplish, shiny, kind of tough,
that is a good indicator on assessment
that this is arterial disease in your patient.
And lastly, there can be ulcers which are really a big deal.
This can actually be from venous issues, arterial issues,
or just pressure ulcers, especially at the heel.
Now, these can be very painful. They can be dangerous.
And they need special and prompt attention.
Some additional considerations
when we're talking about assessing a patient's skin
is looking at some consistency factors.
So one of those is moisture if there's excess moisture
or the patient is sweating or what we call diaphoresis.
Next is temperature.
So something to really note that if there's a particular area,
especially like a surgical incision,
and we touch the patient's skin, and it's really hot around those areas.
That could be something to know and could indicate infection.
Now, just note on the opposite end,
that let's say you're assessing a patient, feet for example.
And they have arterial disease,
meaning lack of blood flow or limited blood flow to their legs.
Now, if we touch or assess the patient's lower legs and feet,
and it's really abnormally cold,
this could mean that there's poor perfusion.
And we also want to note this to the health care provider.
So texture is a little bit different.
Some patients have different textures to their skin,
but you want to talk with your patient
and see if this is normal for them,
or something that needs to be addressed.
And lastly, turgor is also an important consideration
when we're talking about hydration status of our patient.
Now, you see here,
the image is at the back of the patient's hand.
Now, as you can imagine overtime, especially with aging,
the skin behind the hand can get kind of loose.
So ideally, it's best to assess this by the patient's chest wall,
grabbing the patient's and pinching up a little skin,
pulling it back and releasing.
So this should snap back rather quickly.
And this means that there's good hydration
and a good hydration status for your patient.
But if you pinch-up the skin, and then you let it go,
and it's kind of slow to return to normal,
that may mean that the patient is severely dehydrated,
and we need to address this.
So, another thing to keep in mind when we're talking about the skin,
and we're assessing this is especially looking at the surface.
Are there any wounds? Are there any lesions?
So if you take a look at this image,
if you see any sort of asymmetry to the lesion,
if it's an abnormal color, if the diameter has changed,
if the border is oddly shaped,
this is something that you may encourage
the actual patient to follow up with a healthcare provider
to see if this is a cancerous lesion or something that's benign.
So next, let's talk about nails.
So you may not think that this is something
that's really that important.
But it actually can tell us a lot
about the nutritional status of the patient
if they've gotten infections, or had traumas,
or even if there's long-term oxygenation problems
with the patient.
So if you take a look at this image,
you see this purplish color in the nail,
that usually could mean like trauma, for example.
I know one of my nails turn purple
when I accidentally shut my nail on the car door, for example.
So next is yellowing.
So this is actually important
because this can mean that your patient has nutritional
or a vitamin deficiency.
Or it could even indicate that there's a fungal infection
that needs to be treated.
Now next, in the middle of this slide,
you see what we call clubbing.
So you see how if you look at the nail,
it's normal, it's pretty flat.
But if you see this distorted kind of a raised nail bed,
we call that clubbing
and that's usually indicates that the patient has had
long-term oxygenation issues.
This is commonly going to be seen with our patients who have COPD.
Now next, looking at texture with our patient.
Now, if you look at the patient's nails,
and they're brittle,
and like really ridges and bumpy or broken,
this can mean that there's also nutritional deficiencies
or long-term disease.
So moving along with our head to toe assessment,
as you can imagine,
there may be various drains, or tubes, or IV lines
that must be assessed by us as nursing.
So it's really important to check the insertion or that surgical site.
So we've got to look for signs of infection
in the cleanliness around that site,
any odd discharger like you see here on this image,
is there any odd discharge on the dressing?
Is there any redness around the insertion site?
You see weird pus or drainage coming out.
All of this is especially important
with any sort of drain tube or IV line
and you need to report that immediately.
So sometimes you've got to communicate
with your healthcare provider.
Sometimes this indicates that that drain, tube, or IV line
must be removed.
And next, when you're talking about
assessing any sort of drains or tubes, for example,
it's really important that we maintain those appropriately.
Now, what I mean by this is if you look in this image here,
you see a very common surgical drain that usually comes from an incision.
So this is gonna help collect any excess drainage or blood.
Now, the one you see in this image is very common,
and we call this a JP drain or a Jackson-Pratt drain.
Now, when you're looking at maintaining drains or tubes,
any drain such as this,
you want to make sure there's no kinks in the tubing
is not being pulled on.
Many times this is collecting excess fluid
from that specific incision.
Also depending on the equipment,
there may be a certain mechanism for suction.
So make sure this is applied, if appropriate.