intergumentary system assesment

Part 1: As the unit manager of a medical-surgical unit, you conduct monthly audits of the staff nurses’ clinical documentation. During this month’s audit, you come across a nurse’s clinical notes which you find to be unnecessarily lengthy. You suspect this may be due to her not knowing the relevant definitions for the assessment findings that she is coming across.

As part of your counseling, you decide to offer assistance in identifying the proper terminology that is associated with common unexpected findings. Use the table below to identify the appropriate terminology:

Nurse’s Notes

Your Succinct Terminology/Proper Definitions (x2 per entry)

There was so much sweat on the patient’s face, arms, and body; he looked drenched. Also, the skin was very yellow

When I pinched the skin of his arm, it just stayed there and would not go back to normal.Also, his other arm was all black and blue.

There was a lot of hair loss on the patient scalp. Also, right on top, there was this lesion that looked like a snake.

Her legs and arms were covered with so much hair; I have never seen a woman look like that. Also, there were also lots of acne pimples.

The nail of the patient’s thumb looked like a spoon. The edges were curved upward but the middle was depressed. Also, between the toes there were these cracks on the skin; he said it was from Athlete’s foot.

I saw a spot (skin lesion) on his face that was flat, very small in size, and circumscribed. Also, his chest was covered with tiny, flat, reddish-purple, tiny little spots which he said are caused by “intravascular defects”.

The lesion on her arm was small, elevated and firm, like a wart. Also, her fingernails were blue.

Her surgery was 9 months ago but her scar still looks bad; it’s irregular in shape, kind of like a snake, elevated, and has grown well-beyond the borders of where the surgery was.

She has a pressure ulcer on the heel and to me it looked like part of the bone was showing. Unless maybe that was the tendon? Also, the other heel was red and when I pressed on the skin with my finger, it would not turn pale the way it is supposed to.

Part 2: Address the questions posed in the following evolving case study

The unlicensed assistive personnel (UAP) reports to the RN that a hospitalized patient presents with an area of skin breakdown on the back of the head.

Q: What is the first step for the RN to take?

Answer:

Upon arriving at the patient’s bed side, the RN notes a 2 cm x 5 cm lesion on the occipital aspect of the patient’s head.

Q: What questions should the RN ask of the UAP to determine the etiology of the skin breakdown?

Answer:

Q: What relevant data from the patient’s record should the RN review to further explore the possible etiology?

Answer:

The RN identifies that the etiology for this wound is pressure.

Q: In addition to occiputs, what other areas of the body are considered pressure points?

Answer:

Upon further assessment of the wound, the RN notes that it presents as a partial-thickness loss of dermis, a shiny open ulcer, with pink wound bed and no slough or bruising.

Q: What stage would the RN diagnose this pressure ulcer as?

Answer:

Q: How does the RN differentiate between the four stages of pressure ulcer development?

Answer: