Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 23: Nursing Assessment: Integumentary System Answer Guidelines 1. A primary concern is skin breakdown. 2. The patient is at risk because of her poor nutritional status, skin that is already showing signs of frailty, and the constant friction, sheer, and pressure caused by the traction and her immobility in the bed. 3. This patient requires a comprehensive skin assessment. 4. The patients health history will indicate previous trauma, surgery, or prior disease that involves the skin. You should determine whether the patient has noticed any dermatologic manifestations of systemic problems, such as jaundice (liver disease), delayed wound healing (diabetes mellitus), and pallor (anemia). Table 24-10 lists diseases with dermatologic manifestations. Specific information related to food sensitivities, pet or drug allergies, and skin reactions to insect bites and stings should also be obtained. Another concern with residents in long-term care facilities is whether there has been any neglect or abuse. Carefully assess for bruises, healed scars, and other skin injuries. 5. The skin assessment components as listed in Table 3-5 include inspecting and palpating the skin for the following: Color Breakdown, lacerations, lesions Scars, tattoos, piercings Bruises, rash Edema Moisture Texture Temperature Turgor Vascularity 6. The low albumin and prealbumin levels are the laboratory values of greatest concern, because they indicate very poor nutritional status, which is a significant risk for skin breakdown and poor healing. 7. A website (http://www.nhlbisupport.com/bmi/) calculation gives 16.6 kg/m2 for her body mass index, which is significantly underweight. This contributes to the evidence that her nutritional status is poor.

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