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Chapter 51:
Patient Assessment:
Integumentary System
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
History Assessment: OPQRST
• Onset: When did the symptoms start?
• Precipitating factor: Is it associated with dry skin? Foods?
Allergies?
• Quality: Is it itchy? Burning? Stinging? Describe your
symptoms in your own words.
• Radiation: Has it spread from a single area?
• Severity: How bothersome is it to you on a scale of 1 to 10?
• Timing: How long has it lasted?
• Medication review: What medications are you taking?
Antibiotics? Steroids? Are you allergic to anything?
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
In an African-American patient, a decrease in
oxyhemoglobin to the skin would result in:
A. Jaundice skin color
B. Vitiligo
C. Cyanosis
D. Ashy skin color
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
D. Ashy skin color
Rationale: A decreased oxyhemoglobin level in a dark-
skinned patient is seen as an ashy skin color.
Jaundice would be seen as a greenish-yellow cast to
the mucous membranes first. Vitiligo may be seen in
dark-skinned patients, but it is the absence of
pigment. Cyanosis would be seen in the mucous
membranes.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Inspection: Color of the Skin
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
When admitting an elderly woman to the ICU, the nurse
notes many small, bright-red lesions around her face and
neck. The nurse is most likely observing:
A. Spider nevus
B. Cherry angiomas
C. Nevus flammeus
D. Telangiectasias
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. Cherry angiomas
Rationale: Cherry angiomas are small, bright-red lesions;
they are normal. Spider nevi, small veins that terminate
in a central point, are abnormal. Nevus flammeus is a
birthmark. Telangiectasias are irregular fine red lines
associated with superficial blood vessels.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Skin Lesions
• Described by color, shape,
location, appearance,
distribution, and size
• Abnormal lesions
• Vascular lesions (normal)
– Purpura
– Petechiae
– Nevus flammeus
– Ecchymoses
– Telangiectasias
– Spider angiomas
– Cherry angiomas
– Urticaria
– Immature hemangioma
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment for Skin, Hair, and Nail
Infections
• Rashes
–
Superficial to deep tissue invasion
–
Opportunistic infections
–
Observation for candidiasis
• Hair
–
Alopecia
–
Hirsutism
• Nails
–
Capillary refill
–
Cyanosis
–
Nail contour and shape: clubbing, spoon-shaped nails
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Palpation
• Texture
• Mobility/turgor
• Moisture
• Edema
• Temperature
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Edema Scale
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment for Pressure Ulcers
• High-risk patients
– Incontinent of
bowel/bladder
– Decreased sensation
– Decreased circulation
– Dark-skinned patients
• Braden’s Assessment Scale
• Treatment
– Turning regimen
– Clean, dry skin
– Decrease friction/shear
– Pad appliances, wounds,
etc.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Dark-skinned patients have the highest risk of skin cancer.
A. True
B. False
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. False
Rationale: Fair-skinned patients with exposure to sun have
the highest risk of developing skin cancer.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment of Skin Tumors
• Basal cell carcinoma
• Squamous cell carcinoma
• Malignant melanoma
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins