Integumentary System

Kyle Michaels is a 55 y.o. male with history of type II Diabetes Mellitus, Hypertension, Hyperlipidemia, Coronary Artery Disease, and Diabetic Foot ulcer, presents to the emergency department with chief complaint of worsening sacral ulcer. Patient resides at home and was receiving home health wound care and eventually progressed into needing IV antibiotics and was suggested to go to the ED for worsening infection.

Inpatient Hospital Room

1. Identify the components of a comprehensive integumentary assessment, including skin color, temperature, moisture, texture, turgor, lesions, and integrity.
2. Use inspection and palpation techniques to assess the patient’s skin from head to toe, including high-risk pressure areas.
3. Recognize and describe abnormal skin findings, such as rashes, ulcers, bruising, pressure injuries, excoriation, or dryness.
4. Differentiate between primary and secondary skin lesions, and use appropriate terminology to describe their characteristics (e.g., size, shape, distribution).
5. Assess the patient’s risk for impaired skin integrity, using tools such as the Braden Scale.
6. Use therapeutic communication techniques to engage the patient in reporting symptoms such as itching, pain, or changes in skin appearance.
7. Document findings accurately, including detailed descriptions of abnormalities and interventions as needed.

1. Perform a full skin assessment using correct techniques and sequence.
2. Identify and describe generalized skin abnormalities using medical terminology (e.g., macules, papules, pustules, excoriation, edema).
3. Assess for risk factors contributing to skin breakdown or delayed wound healing.
4. Communicate with the patient regarding their symptoms, concerns, hygiene practices, and skincare routine.
5. Initiate appropriate nursing interventions such as repositioning or skin barrier application when indicated.
6. Document skin findings clearly, including size, location, stage (if pressure injury), drainage, and color, using structured or narrative formats.