{"id":3739,"date":"2018-11-12T22:24:49","date_gmt":"2018-11-13T03:24:49","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&#038;p=3739"},"modified":"2020-03-23T18:17:25","modified_gmt":"2020-03-23T22:17:25","slug":"2-12-head-to-toe-assessment-integument-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-12-head-to-toe-assessment-integument-assessment\/","title":{"raw":"2.12 Head-to-Toe Assessment: Integument Assessment","rendered":"2.12 Head-to-Toe Assessment: Integument Assessment"},"content":{"raw":"Checklist 22 provides a guide for objective and subjective data collection in an integument assessment.\r\n<table style=\"border-collapse: collapse;width: 99.9268%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 99.9269%\" colspan=\"2\">\r\n<h3 style=\"text-align: center\"><a id=\"checklist22\"><\/a>Checklist 22: Integument Assessment<\/h3>\r\n[caption id=\"attachment_3688\" align=\"aligncenter\" width=\"293\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-3688 \" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers-300x233.jpg\" alt=\"\" width=\"293\" height=\"228\" \/><\/a> Figure 2.32 Integumentary system[\/caption]\r\n<h5 style=\"text-align: center\">Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 99.9269%\" colspan=\"2\">\r\n<h5><span style=\"color: #000000\">Safety considerations:<\/span><\/h5>\r\n<ul>\r\n \t<li><span style=\"color: #333333\">Perform hand hygiene.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Introduce yourself to patient.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Explain process to patient.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Be organized and systematic in your assessment.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Use appropriate listening and questioning skills.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Listen and attend to patient cues.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Ensure patient's privacy and dignity.<\/span><\/li>\r\n \t<li>Document according to your agency's policies and guidelines.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border-collapse: collapse;width: 99.9268%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 99.9269%\" colspan=\"2\">\r\n<h3 style=\"text-align: center\">Objective Data<\/h3>\r\n<h5 style=\"text-align: center\">Consider the following:<\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">\r\n<h4 style=\"text-align: center\">Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">&nbsp;\r\n<ul>\r\n \t<li>Observe the skin from head to toe for colour, moisture, temperature, hair loss<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">Abnormalities in skin \/ sclera colour may indicate other health issues (i.e., jaundice)\r\n\r\n[caption id=\"attachment_4200\" align=\"aligncenter\" width=\"200\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-4200\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye-300x214.jpg\" alt=\"\" width=\"200\" \/><\/a> Figure 2.33 Jaundiced sclera[\/caption]\r\n\r\nConsider causes of excessive moisture. Excess moisture may increase the patient's risk for skin breakdown.\r\n\r\nExcessive temperature may indicate infection. Further assessment is required.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\r\n<ul>\r\n \t<li>Observe condition of nails, eyes, and mucous membranes of nose and mouth<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">Neglect of nails may suggest difficulty with managing activities of daily living.\r\n\r\nFungal infection of nails is common.\r\n\r\n[caption id=\"attachment_4204\" align=\"aligncenter\" width=\"200\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection.png\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-4204 size-medium\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection-300x194.png\" alt=\"\" width=\"200\" \/><\/a> Figure 2.34 Fungal nail infection (resolving)[\/caption]<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\r\n<ul>\r\n \t<li>Observe condition of mouth (evidence of oral care or lack thereof)<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">\r\n\r\n[caption id=\"attachment_4209\" align=\"aligncenter\" width=\"200\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-4209 size-full\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral.jpg\" alt=\"\" width=\"200\" \/><\/a> Figure 2.36 \u00a0 oral herpes[\/caption]\r\n\r\n[caption id=\"attachment_4207\" align=\"aligncenter\" width=\"200\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/oral-candida.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-4207 size-full\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/oral-candida.jpg\" alt=\"\" width=\"200\" \/><\/a> Figure 2.35 Oral candida[\/caption]\r\n<ul>\r\n \t<li>Mucous membranes of the mouth should be moist. Lack of moisture may suggest dehydration. Further assessment is required.<\/li>\r\n \t<li>Poor oral health can be evidence of larger health or social issues. Further assessment is required.<\/li>\r\n \t<li>Oral candida can occur with antibiotic therapy and from inhaled corticosteroids.<\/li>\r\n \t<li>Oral care should be a routine part of every patient's care plan.<\/li>\r\n \t<li>Herpes infections are contagious. Risk assessment and implementation of PPE should be considered.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\r\n<ul>\r\n \t<li>Assess skin integrity\u00a0for presence of lesions, rashes, or pressure injury.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">The integumentary system is our body's first line of defense against invading organisms. Breaks in integument increase one's risk of infection. Any concerns should be reported to the appropriate healthcare provider immediately.\r\n\r\n[caption id=\"attachment_4201\" align=\"aligncenter\" width=\"200\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-4201\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08-300x225.jpg\" alt=\"\" width=\"200\" \/><\/a> Figure 2.37 Scabies[\/caption]\r\n\r\n[caption id=\"attachment_4202\" align=\"aligncenter\" width=\"200\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img class=\"wp-image-4202\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot.jpg\" alt=\"\" width=\"200\" \/><\/a> Figure 2.38 Gangrene[\/caption]<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\r\n<ul>\r\n \t<li>Inspect dressings and\/or entry sites of all tubes, drains, and IVs.<\/li>\r\n<\/ul>\r\n<strong>\u00a0<\/strong><\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">Determine the rationale for all tubes.\u00a0Tubes should be secured, intact, and functioning. See <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/10-2-caring-for-patients-with-tubes-and-devices\/\">Table 10.1 Guidelines for Caring for Patients with Tubes and Devices.<\/a>\r\n\r\nDressings should be dry and intact.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\r\n<ul>\r\n \t<li>Note the amount, colour, and consistency of drainage from any tube.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 55.3386%\">The character of drainage provides insight into activities within the body.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border-collapse: collapse;width: 99.9268%;height: 190px\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">\r\n<h3 style=\"text-align: center\">Subjective Data<\/h3>\r\n<h5 style=\"text-align: center\">Ask if they have noticed any recent changes to their skin.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">\r\n<h4 style=\"text-align: left\">Focused integument assessment may also include:<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 174px\">\r\n<td style=\"border: 1px solid #000000;width: 51.0521%;height: 174px\"><strong>Pressure Injury Risk Assessment<\/strong>\r\n\r\n<strong>Braden scales<\/strong> for measuring risk of developing a pressure injury are widely used in North America in the adult patient population. The tool consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Using each of these elements, the nurse assigns a score. Low numbers translate to high risk of pressure injury.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 48.8747%;height: 174px\">See <a href=\"https:\/\/www.alberta.ca\/assets\/documents\/aadl\/aadl-braden-assessment.pdf\">Braden Pressure Ulcer Risk Assessment<\/a>\r\n\r\nSome agencies have guidelines about frequency of assessment and documentation using a Braden Scale.\r\n\r\nIt is important for the nurse to remember that the Braden Scale is an assessment tool. The nursing process isn\u2019t completed unless risk is addressed through preventative strategies and evaluation of outcomes.\r\n\r\nNecessary interventions to prevent and treat pressure injury should be included in the plan of care.<\/td>\r\n<\/tr>\r\n<tr style=\"height: 16px\">\r\n<td style=\"border: 1px solid #000000;width: 51.0521%;height: 16px\"><strong>Wound Assessment<\/strong><\/td>\r\n<td style=\"border: 1px solid #000000;width: 48.8747%;height: 16px\">See <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/4-2-wound-healing-and-assessment\/\">4.2 Wound Healing and Assessment<\/a><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">Potential integument related nursing diagnoses:\r\n<ul>\r\n \t<li>Impaired skin integrity due to incontinence.<\/li>\r\n \t<li>Risk of pressure injury due to immobility.<\/li>\r\n \t<li>Risk of wound infection due to contamination of coccyx wound with fecal matter.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">Data sources: Braden &amp; Bergstrom, 1989; RNAO, 2016; Potter et al., 2019<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>Identify the six components of the Braden Scale that suggest risk of pressure injury.<\/li>\r\n \t<li>In five of those components, provide two possible preventative strategies to reduce risk of pressure injury.<\/li>\r\n<\/ol>\r\n<\/div>\r\n<h2>Attribution:<\/h2>\r\nFigure 2.32 <a href=\"https:\/\/en.wikipedia.org\/wiki\/File:Skin_layers.png\">Layers of Skin<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Madhero88\">Madhero88<\/a> and M. Komorniczak is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Creative Commons Attribution-Share Alike 3.0 Unported license.<\/a>\r\nFigure 2.33 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Jaundice_eye.jpg\">Jaundice Caused by Hepatitis A<\/a> by\u00a0CDC\/Dr. Thomas F. Sellers\/Emory University is in the <a href=\"https:\/\/en.wikipedia.org\/wiki\/Public_domain\">public domain<\/a>.\r\nFigure 2.34 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:A_patient%27s_left_foot_-_after_ten_weeks_of_Terbinafine_oral_treatment.png\">A Patient's Left Foot - After Ten Weeks of Terbinafine Oral Treatment<\/a> by\u00a0Dandandandandandandan2014\u00a0is used under a\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a>\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">Attribution-Share Alike 4.0 International<\/a>\u00a0license.\r\nFigure 2.35 <a href=\"https:\/\/en.wikipedia.org\/wiki\/Oral_candidiasis#\/media\/File:Human_tongue_infected_with_oral_candidiasis.jpg\">Thrush in a Child Who Has Taken Antibiotics<\/a> by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Jmh649\">James Heilman, MD<\/a>\u00a0is used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Creative Commons Attribution-Share Alike 3.0 Unported license.<\/a>\r\nFigure 2.36 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Herpes_labialis_-_opryszczka_wargowa.jpg\">Herpes Labialis<\/a> by\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/pl:user:Jojo\">Jojo<\/a>\u00a0is in the\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/Public_domain\">public domain.<\/a>\r\nFigure 2.37 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:ScabiesD08.JPG\">Scabies<\/a> by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Cixia&amp;action=edit&amp;redlink=1\">Cixia<\/a>\u00a0is in the <a href=\"https:\/\/en.wikipedia.org\/wiki\/Public_domain\">public domain.<\/a>\r\nFigure 2.38 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:GangreneFoot.JPG\">Gangrene Toe<\/a> by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Jmh649\">James Heilman, MD<\/a>\u00a0is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/\">CC BY-SA license.<\/a>\r\n<div id=\"mw-mf-viewport\">\r\n<div id=\"mw-mf-page-center\">\r\n<div id=\"bodyContent\" class=\"content\">\r\n<div id=\"mw-content-text\">\r\n<div id=\"shared-image-desc\"><\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>","rendered":"<p>Checklist 22 provides a guide for objective and subjective data collection in an integument assessment.<\/p>\n<table style=\"border-collapse: collapse;width: 99.9268%\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000;width: 99.9269%\" colspan=\"2\">\n<h3 style=\"text-align: center\"><a id=\"checklist22\"><\/a>Checklist 22: Integument Assessment<\/h3>\n<figure id=\"attachment_3688\" aria-describedby=\"caption-attachment-3688\" style=\"width: 293px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3688\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers-300x233.jpg\" alt=\"\" width=\"293\" height=\"228\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers-300x233.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers-65x50.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers-225x174.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers-350x271.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Skin_layers.jpg 360w\" sizes=\"auto, (max-width: 293px) 100vw, 293px\" \/><\/a><figcaption id=\"caption-attachment-3688\" class=\"wp-caption-text\">Figure 2.32 Integumentary system<\/figcaption><\/figure>\n<h5 style=\"text-align: center\">Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.<\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 99.9269%\" colspan=\"2\">\n<h5><span style=\"color: #000000\">Safety considerations:<\/span><\/h5>\n<ul>\n<li><span style=\"color: #333333\">Perform hand hygiene.<\/span><\/li>\n<li><span style=\"color: #333333\">Introduce yourself to patient.<\/span><\/li>\n<li><span style=\"color: #333333\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\n<li><span style=\"color: #333333\">Explain process to patient.<\/span><\/li>\n<li><span style=\"color: #333333\">Be organized and systematic in your assessment.<\/span><\/li>\n<li><span style=\"color: #333333\">Use appropriate listening and questioning skills.<\/span><\/li>\n<li><span style=\"color: #333333\">Listen and attend to patient cues.<\/span><\/li>\n<li><span style=\"color: #333333\">Ensure patient&#8217;s privacy and dignity.<\/span><\/li>\n<li>Document according to your agency&#8217;s policies and guidelines.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-collapse: collapse;width: 99.9268%\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000;width: 99.9269%\" colspan=\"2\">\n<h3 style=\"text-align: center\">Objective Data<\/h3>\n<h5 style=\"text-align: center\">Consider the following:<\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">\n<h4 style=\"text-align: center\">Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">&nbsp;<\/p>\n<ul>\n<li>Observe the skin from head to toe for colour, moisture, temperature, hair loss<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">Abnormalities in skin \/ sclera colour may indicate other health issues (i.e., jaundice)<\/p>\n<figure id=\"attachment_4200\" aria-describedby=\"caption-attachment-4200\" style=\"width: 200px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" class=\"wp-image-4200\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye-300x214.jpg\" alt=\"\" width=\"200\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye-300x214.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye-65x46.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye-225x161.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Jaundice_eye.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-4200\" class=\"wp-caption-text\">Figure 2.33 Jaundiced sclera<\/figcaption><\/figure>\n<p>Consider causes of excessive moisture. Excess moisture may increase the patient&#8217;s risk for skin breakdown.<\/p>\n<p>Excessive temperature may indicate infection. Further assessment is required.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\n<ul>\n<li>Observe condition of nails, eyes, and mucous membranes of nose and mouth<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">Neglect of nails may suggest difficulty with managing activities of daily living.<\/p>\n<p>Fungal infection of nails is common.<\/p>\n<figure id=\"attachment_4204\" aria-describedby=\"caption-attachment-4204\" style=\"width: 200px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection.png\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" class=\"wp-image-4204 size-medium\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection-300x194.png\" alt=\"\" width=\"200\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection-300x194.png 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection-65x42.png 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection-225x146.png 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Fungal-nail-infection.png 320w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-4204\" class=\"wp-caption-text\">Figure 2.34 Fungal nail infection (resolving)<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\n<ul>\n<li>Observe condition of mouth (evidence of oral care or lack thereof)<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">\n<figure id=\"attachment_4209\" aria-describedby=\"caption-attachment-4209\" style=\"width: 200px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" class=\"wp-image-4209 size-full\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral.jpg\" alt=\"\" width=\"200\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral.jpg 259w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/herpes-oral-225x169.jpg 225w\" sizes=\"(max-width: 259px) 100vw, 259px\" \/><\/a><figcaption id=\"caption-attachment-4209\" class=\"wp-caption-text\">Figure 2.36 \u00a0 oral herpes<\/figcaption><\/figure>\n<figure id=\"attachment_4207\" aria-describedby=\"caption-attachment-4207\" style=\"width: 200px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/oral-candida.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" class=\"wp-image-4207 size-full\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/oral-candida.jpg\" alt=\"\" width=\"200\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/oral-candida.jpg 197w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/oral-candida-65x84.jpg 65w\" sizes=\"(max-width: 197px) 100vw, 197px\" \/><\/a><figcaption id=\"caption-attachment-4207\" class=\"wp-caption-text\">Figure 2.35 Oral candida<\/figcaption><\/figure>\n<ul>\n<li>Mucous membranes of the mouth should be moist. Lack of moisture may suggest dehydration. Further assessment is required.<\/li>\n<li>Poor oral health can be evidence of larger health or social issues. Further assessment is required.<\/li>\n<li>Oral candida can occur with antibiotic therapy and from inhaled corticosteroids.<\/li>\n<li>Oral care should be a routine part of every patient&#8217;s care plan.<\/li>\n<li>Herpes infections are contagious. Risk assessment and implementation of PPE should be considered.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\n<ul>\n<li>Assess skin integrity\u00a0for presence of lesions, rashes, or pressure injury.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">The integumentary system is our body&#8217;s first line of defense against invading organisms. Breaks in integument increase one&#8217;s risk of infection. Any concerns should be reported to the appropriate healthcare provider immediately.<\/p>\n<figure id=\"attachment_4201\" aria-describedby=\"caption-attachment-4201\" style=\"width: 200px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" class=\"wp-image-4201\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08-300x225.jpg\" alt=\"\" width=\"200\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08-300x225.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08-225x168.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/ScabiesD08.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-4201\" class=\"wp-caption-text\">Figure 2.37 Scabies<\/figcaption><\/figure>\n<figure id=\"attachment_4202\" aria-describedby=\"caption-attachment-4202\" style=\"width: 200px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot.jpg\" target=\"_blank\" rel=\"noopener noreferrer\"><img decoding=\"async\" class=\"wp-image-4202\" style=\"font-weight: bold;font-family: inherit;font-size: inherit\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot.jpg\" alt=\"\" width=\"200\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot.jpg 262w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot-65x60.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/GangreneFoot-225x206.jpg 225w\" sizes=\"(max-width: 262px) 100vw, 262px\" \/><\/a><figcaption id=\"caption-attachment-4202\" class=\"wp-caption-text\">Figure 2.38 Gangrene<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\n<ul>\n<li>Inspect dressings and\/or entry sites of all tubes, drains, and IVs.<\/li>\n<\/ul>\n<p><strong>\u00a0<\/strong><\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">Determine the rationale for all tubes.\u00a0Tubes should be secured, intact, and functioning. See <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/10-2-caring-for-patients-with-tubes-and-devices\/\">Table 10.1 Guidelines for Caring for Patients with Tubes and Devices.<\/a><\/p>\n<p>Dressings should be dry and intact.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 44.5883%\">\n<ul>\n<li>Note the amount, colour, and consistency of drainage from any tube.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 55.3386%\">The character of drainage provides insight into activities within the body.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-collapse: collapse;width: 99.9268%;height: 190px\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">\n<h3 style=\"text-align: center\">Subjective Data<\/h3>\n<h5 style=\"text-align: center\">Ask if they have noticed any recent changes to their skin.<\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">\n<h4 style=\"text-align: left\">Focused integument assessment may also include:<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"height: 174px\">\n<td style=\"border: 1px solid #000000;width: 51.0521%;height: 174px\"><strong>Pressure Injury Risk Assessment<\/strong><\/p>\n<p><strong>Braden scales<\/strong> for measuring risk of developing a pressure injury are widely used in North America in the adult patient population. The tool consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Using each of these elements, the nurse assigns a score. Low numbers translate to high risk of pressure injury.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 48.8747%;height: 174px\">See <a href=\"https:\/\/www.alberta.ca\/assets\/documents\/aadl\/aadl-braden-assessment.pdf\">Braden Pressure Ulcer Risk Assessment<\/a><\/p>\n<p>Some agencies have guidelines about frequency of assessment and documentation using a Braden Scale.<\/p>\n<p>It is important for the nurse to remember that the Braden Scale is an assessment tool. The nursing process isn\u2019t completed unless risk is addressed through preventative strategies and evaluation of outcomes.<\/p>\n<p>Necessary interventions to prevent and treat pressure injury should be included in the plan of care.<\/td>\n<\/tr>\n<tr style=\"height: 16px\">\n<td style=\"border: 1px solid #000000;width: 51.0521%;height: 16px\"><strong>Wound Assessment<\/strong><\/td>\n<td style=\"border: 1px solid #000000;width: 48.8747%;height: 16px\">See <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/4-2-wound-healing-and-assessment\/\">4.2 Wound Healing and Assessment<\/a><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">Potential integument related nursing diagnoses:<\/p>\n<ul>\n<li>Impaired skin integrity due to incontinence.<\/li>\n<li>Risk of pressure injury due to immobility.<\/li>\n<li>Risk of wound infection due to contamination of coccyx wound with fecal matter.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 51.0521%\" colspan=\"2\">Data sources: Braden &amp; Bergstrom, 1989; RNAO, 2016; Potter et al., 2019<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>Identify the six components of the Braden Scale that suggest risk of pressure injury.<\/li>\n<li>In five of those components, provide two possible preventative strategies to reduce risk of pressure injury.<\/li>\n<\/ol>\n<\/div>\n<h2>Attribution:<\/h2>\n<p>Figure 2.32 <a href=\"https:\/\/en.wikipedia.org\/wiki\/File:Skin_layers.png\">Layers of Skin<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Madhero88\">Madhero88<\/a> and M. Komorniczak is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Creative Commons Attribution-Share Alike 3.0 Unported license.<\/a><br \/>\nFigure 2.33 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Jaundice_eye.jpg\">Jaundice Caused by Hepatitis A<\/a> by\u00a0CDC\/Dr. Thomas F. Sellers\/Emory University is in the <a href=\"https:\/\/en.wikipedia.org\/wiki\/Public_domain\">public domain<\/a>.<br \/>\nFigure 2.34 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:A_patient%27s_left_foot_-_after_ten_weeks_of_Terbinafine_oral_treatment.png\">A Patient&#8217;s Left Foot &#8211; After Ten Weeks of Terbinafine Oral Treatment<\/a> by\u00a0Dandandandandandandan2014\u00a0is used under a\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a>\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">Attribution-Share Alike 4.0 International<\/a>\u00a0license.<br \/>\nFigure 2.35 <a href=\"https:\/\/en.wikipedia.org\/wiki\/Oral_candidiasis#\/media\/File:Human_tongue_infected_with_oral_candidiasis.jpg\">Thrush in a Child Who Has Taken Antibiotics<\/a> by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Jmh649\">James Heilman, MD<\/a>\u00a0is used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Creative Commons Attribution-Share Alike 3.0 Unported license.<\/a><br \/>\nFigure 2.36 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Herpes_labialis_-_opryszczka_wargowa.jpg\">Herpes Labialis<\/a> by\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/pl:user:Jojo\">Jojo<\/a>\u00a0is in the\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/Public_domain\">public domain.<\/a><br \/>\nFigure 2.37 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:ScabiesD08.JPG\">Scabies<\/a> by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Cixia&amp;action=edit&amp;redlink=1\">Cixia<\/a>\u00a0is in the <a href=\"https:\/\/en.wikipedia.org\/wiki\/Public_domain\">public domain.<\/a><br \/>\nFigure 2.38 <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:GangreneFoot.JPG\">Gangrene Toe<\/a> by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Jmh649\">James Heilman, MD<\/a>\u00a0is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/\">CC BY-SA license.<\/a><\/p>\n<div id=\"mw-mf-viewport\">\n<div id=\"mw-mf-page-center\">\n<div id=\"bodyContent\" class=\"content\">\n<div id=\"mw-content-text\">\n<div id=\"shared-image-desc\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"author":397,"menu_order":12,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-3739","chapter","type-chapter","status-publish","hentry"],"part":102,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3739","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":26,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3739\/revisions"}],"predecessor-version":[{"id":5197,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3739\/revisions\/5197"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/102"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3739\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=3739"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=3739"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=3739"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=3739"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}