ASSESSING INTEGUMENTARY

IMPLEMENTATION
Prior to performing the procedure,
1. Perform handwashing, and sanitize hand
Hand washing technique:
Medical
Surgical

2. Introduce yourself to the client and identify client’s identity, explain what you are going to do, why it
is necessary, and how the client can cooperate. and secure client consent
How to Identify Clients name?
Patient wrist band
Ask patient Full name
Patient Bed. Number/room

3. Gather the necessary equipment.

Equipment:
Millimeter Ruler, Examination
gloves, Magnifying glass
Equipment:
Millimeter Ruler, Examination gloves, Magnifying glass
4. Provide Privacy,
Draw curtain for privacy before performing a procedure,

5. Provide safety environment to both patient and nurse, include:

Sharp injuries
Exposure to blood pathogens
Lifting injuries
Lack of PPE

6. Raise bed side rails

To prevent patient from risk for fall

1. Wash hands
2. Introduce yourself to the client
and identify client’s identity.
Explain what you are going to do,
why it is necessary, and
how the client can cooperate.
3. Gather the necessary equipment.
4. Provide Privacy
PROCEDURE/ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Inspect skin color (best assessed Varies from light to deep brown; Pallor
under natural light and on areas from ruddy pink to light pink; Cyanosis
not exposed to the sun) from yellow overtones to olive) Jaundice
Erythema
Inspect uniformity of skin color Generally uniform except in Areas of either
areas exposed to the sun; areas hyperpigmentation or
of lighter pigmentation (palms, hypopigmentation
lips, nail beds) in dark skinned
people
Assess edema, if present No edema See scale: for grading edema
(location, color, temperature,
shape, and degree to which skin
remains indented or pitted when
pressed by finger)
Measuring circumference of the
extremity with a millimeter tape
may be useful for future
comparison.
Inspect, palpate, and describe Freckles, some birthmarks, Various interruptions in skin
skin lesions. Apply gloves if some flat and raised nevi: No integrity, irregular, multicolored,
lesions are open or draining. abrasions or other lesions or raised nevi
Palpate lesions to determine
shape and texture,
Assess for Malignant lesion
A=symmetry
B=Border of irregularity
C=Color variation
D=Diameter> 0.5 cm
Observe and palpate skin Moisture in skin folds and the Excessive
moisture axillae ( varies with moisture( hyperthermia (fever)
environmental temperature, and Generalized hypothermia
 activity) (shock)
Localized hyperthermia
(infection)
Localized hypothermia
(arteriosclerosis)
Note skin turgor (fullness or When pinched, skin springs Skin stays pinched or tented or
elasticity) by lifting and back to previous state: may be moves back slowly
pinching the skin on an slower in elders (dehydration)
extremity
Document finding in the client record using forms or checklists supplemented by narrative notes when
appropriate by narrative notes when appropriate. Draw location of skin lesions on body surface.