Hi Ninja Nerds! In this video today we're going to be talking about assessing skin color. So if you like this video make sure you give it a thumbs up and go over and check out NinjaNerd.org. That's where we have all of our notes and illustrations for all the lectures that we put up on our YouTube channels for you guys to use and study from.
So let's get started with assessing skin color. So when we're talking about the skin and we're going to be assessing the skin it's a really nice and vital assessment for us to use because it can give us a lot of information about the patient. So when we are documenting in nursing, we always want to document by exception.
What that means is that in our mind, we have a clear view of what is considered normal versus what is considered abnormal. So make sure you're aware of what's going on with your policies and your procedures within your facility, and then you can chart by exception. So today, I'm going to go over what we're talking about when we're assessing by color, meaning we're going to assess our patient.
And when we look at our patient, we're going to assume that their color is a nice... healthy normal color that is going to be appropriate for that patient and what is going on with them. But we also want to note some other words and terms that we can use.
So when we are documenting, we're going to be documenting and understanding what the patient has going on. So the first term we're going to talk about is pallor. And when we're talking about pallor, we're talking about the color of the patient's skin looking pale, right?
So this is the easiest one to start with, right? It's going to be looking pale. Alright, or basically having a lack of color. So these are the patients that when we look at them we're going to say, okay they look kind of white or they're looking like the sheet, like you know they're looking like a ghost, they're looking as white as the sheet on the bed. And that is because we have something going on with the patient that might be indicative of what's going on with them.
So right here I have a couple things drawn here. And in basis, we're going to be thinking of this patient either having a low hemoglobin. What does it mean to us that if they have a low hemoglobin, this patient might be anemic? or have a form of anemia.
It also might mean that this patient is having a low blood volume, which we use another word for that as hypovolemia. Then there could be one other thing going on which is a compression of the area. But let's think about this for a second. We have a patient, we're looking at them, they're looking at them white as a ghost, right? So the coloring from their face is gone.
So I want you to think about how blood works in the body, right? We start having a low blood volume, right, over anemia. So the coloring of the blood vessels within our face is kind of going away.
Why is that going away? We either have a low blood volume, so all that blood is going to our other vital organs, our brain, right, our heart, or our organs within our abdominal cavity. So because of that, the generic or the easiest way for you to think about someone being pale or having pallor is because they're having a lack of Blood flow.
OK? It's a really simple way to think about it. There's a lack of blood flow to that area.
That's why it's turning, looking like it's a little bit of white, right? And because of this, we can start thinking about the assessment when we're looking at this patient. When we're assessing this patient, the easiest way or the most obvious way is their face or their exposed skin. It's going to show us that they're looking kind of pale.
They're looking to have pallor in that area. We can further investigate this patient and assess them by looking at their conjunctiva, right, the eye. So when we looked at that. We're going to see some paleness within that conjunctiva. It's not going to be that nice, bright, pinkish red.
It's going to be looking pale. Also, the lips can be looking pale, right? And then we can also look at the nail beds as well. The nail beds here will just be a little more on the pale side.
They're going to have that nice pink undertone. And when we blanch them, right, when we do our cap refill and blanch, we might see an increase in that cap refill time, right? It's taking longer for blood flow to get to that area.
So all of this together is an assessment for us to think, okay, this patient's pale. And now we can use our nursing brain to think what else might be going on with them. Are they anemic? Are they hypovolemic due to a hemorrhage?
Is there something else going on that we need to ask questions on and investigate from there? So that is pallor. Let's move on to cyanosis.
Now we're on to cyanosis. And when we talk about cyanosis, this is one that's usually pretty easy for people to identify right away. But this is one the coloring is kind of a bluish.
A bluish, grayish... Coloring. So what that means is we have a patient that's got some bluing to the areas that we're going to be identifying, right? Or they have some type of grayish or lack of that pink reddish tone. They can also use the word ashen as well.
That might also be another word you hear. But when we are assessing for cyanosis, we have some risk factors or things that we want to start thinking about. So some of them could be just a cold environment.
Patients been out in a cold environment for a prolonged period of time. Patient has some maybe vasoconstriction that's occurring, whether it is due to the cold environment or some underlying issue that the patient has. Could also be that they have some type of cardiac or respiratory issue. Right.
Whether it's known or not, okay. Because of that, we want to start thinking, what do all these kind of all have in common, right? And for the cyanosis, it's really easy to boil it down to some form of hypoxia, right, to the area, localized hypoxia to these areas. So when we're assessing them, what are we looking at? There's two different forms of cyanosis.
There can be the peripheral cyanosis. And with peripheral cyanosis, these are the things we're going to be assessing like their ears, fingers, toes, because we're looking at the nail beds for them. And then you can also think about the hands and the feet. And then we can also identify central. And what that means is central cyanosis is more of a medical emergency because that's going to be the areas like our lips or around the mouth, the tongue, or the mucosal membranes.
So meaning we have the patients open their mouth, say, ah, we can see that the insides of the mouth are also looking a little bluish or grayish. Okay. So really important here to be able to identify what's going on because within a patient who has some form of cyanosis is this some type of acute right issue which is going into our maybe our central where we were thinking this is more emergency or is it chronic is this somebody who is battling some type of underlying cardiac or respiratory issue so they might have slightly blue fingers they might have slightly cyanotic fingers often more often than not and that is something we also want to note and document as well now let's move on to erythema Now we're going to talk about erythema and with erythema we're going to think of the color as what? We're going to be looking at it as red.
You can also hear the word flush, right, or blush. You can also think about this one as kind of the opposite of pallor, right? So this is where we're going to have this flushing, this redness to the skin. And a question for you, is it blanchable or unblanchable if you have erythema?
It's a trick question. It can actually be a little bit more actually be both, right? You can have erythema that's blanchable and unblanchable. But what are some of the causes or the risk factors that we're looking for?
Well, one of them is easily sunburn. So if we have a patient that has a lot of sun exposure. We can have redness to the skin. Alcohol consumption.
So if you have seen anybody consume alcohol and they start getting really red cheeks, really flush or blushed cheeks, that can also be a cause. We can also have somebody who has a fever. Right here we have somebody who has a fever of 38.5 degrees Celsius which is 101.3 Fahrenheit but someone who has a fever whether it's a systemic related or not we don't know all we know is that if someone has a fever they could have that flushing in the face. So that's something else you're gonna think about.
If someone walks into your, if you walk into your patient's room or you're looking at them and you see they have flushing in the face, you're gonna think, do you have a fever? Now that's one thing so we can check. We can also have somebody who has some type of infection.
Right, and that can be again the fever infection kind of related, someone having a systemic or a localized infection, whether they have something infected on the skin or there's something else going on. And then we can also know injury or... or trauma.
So someone could have redness from getting their hand smashed by a hammer, their thumb smashed by something, right, or they could have a bee sting or a bug bite that's got a little redness in the area. And all of these are kind of an indication to us that there's some sort of vasodilation occurring where those blood vessels are opening up a little bit superficially and we're bringing more blood flow to that area. So it's making us have some type of flush or blusher redness to the area.
So when we're assessing these patients, we can be looking at them, the most obvious is going to be the face, right, within the cheeks predominantly. Could also be looking at their shoulders or anything else exposed to the sun, right, that might have some type of burn or redness, right. And then we can also think about the areas of the trauma, right. So if somebody had some type of bug bite right on their arm, right on their forearm, that area is going to also be. So the areas.
trauma or injury are going to show us erythema. Okay, so that's erythema. Moving on to jaundice.
Alright, last one, jaundice. Let's talk about jaundice. So first thing is, I think this is the most easily identified, jaundice. If someone's coloring is looking what?
They're going to be looking yellow, some even say a little bit of orange. Basically not the same tone of the patient's skin that they normally have. So we have a patient who shows up and they're looking jaundiced. What are we immediately thinking is possibly the cause for this patient to be looking this way? Well, right here I got this nice liver for you.
And we can think either liver or either gallbladder. dysfunction. Okay, and what does that mean? We have an issue with our liver and our gallbladder. It's not working properly and that could lead to us having some red blood cell, RBC, destruction.
And that destruction of red blood cells can cause an increase in what? What is it that could make our skin heal low? It's bilirubin. So with that red blood cell destruction, we have an increase in bilirubin, and that usually is what causes the yellowing of the skin.
Now, does every single person that has jaundice have a liver or gallbladder dysfunction? No, but it's typically something that causes yellowing of the skin. that's going on with the red blood cell destruction that is causing the increase in bilirubin.
If you didn't know, something that you can remember from anatomy physiology is that bilirubin is also what makes our urine yellow and our poop brown. The coloring of bilirubin, if it builds up into the body, it makes a predominant appearance of yellowing of the skin. So when we're assessing this patient, one of the first places that if someone comes in, they're not feeling really well, you can look at their eye, particularly their sclera, and the white of the eye is actually going to look yellow. And because of that manifestation, we can start thinking what else is going on with this patient. Also really easily identified is the face.
There can even be some yellowing of the lips. or the mucosal, right? And all of that is going to signal us that something might be else be going on with this patient, right? They're not just feeling ill. They're also looking jaundiced.
But if we have somebody who is a darker skin tone, it's sometimes harder to identify if the patient is having some type of jaundice or yellowing to the skin. So one of the things that we can do is look at the palms of the hands. and the soles of the feet. The sclera should show as well, right?
And also the mucous membranes, but we also want to think about maybe looking at their hands, right? The soles of their feet and the palms of their hands. We also can do something of this nature. So if...
Is jaundice blanchable? And the answer is technically yes. If you were to blanch a patient who has some type of jaundice, if you blanch them underneath it will look a little more yellow as well. So you can blanch really lightly up on the forehead, press lightly, and then see if there is some type of lightening there and if it looks yellow. So that is the last color that we need to talk about when we're assessing skin.
Now let's just talk quick about the expectations as to what drives the nurse to understand how I'm going to document what the exception the documentation by exception means. So let's talk about that now. Alright NGINers, let's run over quick some of the expectations that we have when we are assessing a patient. And these are also those little nuggets of information that the NCLEX likes to hit on to see if you're reading the question properly and also understanding what's important when we are assessing a patient. So real quick when we do assess a patient, particularly in the in the integumentary assessment, we're going to be looking at cap refill, right?
We're going to pinch the patient or not pinch but apply pressure to the nail bed of the patient while also noting the color and when we do apply that pressure we're looking for a cap refill of what less than or equal to three seconds and that's going to be able to give us information on the patient's bulimic status we're also going to be finding out what's going on with the patient color wise because we're going to be able to look at the skin and the nail beds We can also move into expectations about hair patterns. And when I say expectations or normal, what I'm saying is we have, as human body, have hair in areas that it can and can't be. But that doesn't mean it's wrong if it's in other places.
It's just that there is an expectation of where things should be, and then we note where there shouldn't be. So, for example, we have hair on our head. If someone has a bald spot that we can obviously see, we could document the balding of the area, right? or if they have a hairy patch somewhere that's abnormal to them and something that is to be noted, we also want to put that down within our charting. So that way we know maybe a couple weeks from now or months from now, if it's bigger, smaller, it's looking different, it's changing hair quality, that's also something we can look into.
Because with the integumentary system, it's hair, skin, and nails, right? So we want to make sure that we are always identifying the hair patterns and things that are going on in our patient. We also want to be noting color. color of the skin.
That's what this whole video is about. So we want to make sure that we know what's going on with the patient's color and we're expecting color to be of their normal healthy skin tone, maybe with a little bit of an under coloring so that we know that there is some flushing or an ability to blanch. So we're looking at the color and is it to the patient's typical presentation. We also want to start looking into then the temperature of the patient.
When you're assessing the temperature, you're using the back of the hand and we're checking on both sides. Making sure there's symmetry, making sure the patient doesn't feel too hot, doesn't feel too cold. What we're looking for is that warm and dry.
So we're going to make sure that we have color that is symmetrical. Let's do same because I don't want to mess it up. Same and equal. And then warm, dry. Okay, and then we also want to assess skin turgor.
Remember with turgor, we're assessing the patient's hydration status. So we can use the forearm, clavicle, sternum, or the hand. Hand's not the best, but in a quick area to do it really quickly, we can. But you're just going to pinch a little.
bit of skin and if it stays up the patient might be really dehydrated or if it goes drops down really quickly the patient is adequately hydrated and all of these are just simple little expectations or things that we're going to be looking at for when we take an NCLEX or when we eventually go into a patient's room this is is what we're expecting and then if there is a delineage from that that's where we are charting by exception so we're going to be charting the abnormal or things that are out of the ordinary so I hope this video helps I hope that you learned something from it if you did make sure you hit the thumbs up comment down below and subscribe as always until next time