NCLEX Review: Skin Assessment
The skin is the largest organ of the body and almost every area of nursing requires knowledge of skin assessment. In this video, we will look at concepts you need to know for the NCLEX test, including how to perform a complete and accurate assessment as well as how to maintain skin integrity and prevent skin breakdown. We will explore the stages of pressure ulcers and look at the Braden Scale for Predicting Pressure Ulcer Risk.
Nurse collects data regarding…
- Current symptoms
- Patient’s past history
- Patient’s family history
- Health & lifestyle practices
Guideline for collecting information about symptoms…
Character – Describe the sign or symptom
Onset – When did it begin?
Location – Where is it?
Duration – How long does it last? Does it recur?
Severity – How bad is it? Does it bother you?
Pattern – What makes it better or worse?
Associated factors / How it affects the patient – What other symptoms occur with it? How does it affect you?
Skin assessment involves:
- Inspection – general skin color, color variations, skin integrity, & lesions
- Palpation – texture, thickness, moisture, temperature, turgor, edema
Common skin problem – PRESSURE ULCERS – Localized injuries to the skin and underlying tissue that nearly always develop in areas where there are bones right under the skin
Braden Scale for Predicting Pressure Sore Risk measures…
- Sensory perception – the ability to respond meaningfully to pressure-related discomfort
- Moisture – the degree to which skin is exposed to moisture
- Activity – the degree of physical activity
- Mobility – the ability to change and control body position
- Nutrition – the usual food intake pattern
- Friction and shear