Aseptic Technique Basic Concepts
Open Resources for Nursing (Open RN)
Standard Versus Transmission-Based Precautions
Standard Precautions
Standard precautions are used when caring for all patients to prevent health care associated infections. According to the Centers for Disease Control and Prevention (CDC), standard precautions are “the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered.”[1] They are based on the principle that all blood, body fluids (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. These standards reduce the risk of exposure for the health care worker and protect the patient from potential transmission of infectious organisms.
Current standard precautions according to the CDC (2019) include the following:
- Appropriate hand hygiene
- Use of personal protective equipment (e.g., gloves, gowns, masks, eyewear) whenever infectious material exposure may occur
- Appropriate patient placement and care using transmission-based precautions when indicated
- Respiratory hygiene/cough etiquette
- Proper handling and cleaning of environment, equipment, and devices
- Safe handling of laundry
- Sharps safety (i.e., engineering and work practice controls)
- Aseptic technique for invasive nursing procedures such as parenteral medication administration[2]
Each of these standard precautions is described in more detail in the following subsections.
Transmission-Based Precautions
In addition to standard precautions, transmission-based precautions are used for patients with documented or suspected infection, or colonization, of highly transmissible or epidemiologically important pathogens. Epidemiologically important pathogens include, but are not limited to, Coronavirus disease (COVID-19), Clostridium difficile (C-diff), Methicillin-resistant staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), Respiratory syncytial sirus (RSV), measles, and tuberculosis (TB). For patients with these types of pathogens, standard precautions are used along with specific transmission-based precautions.
There are four categories of transmission-based precautions: contact precautions, enhanced barrier precautions, droplet precautions, and airborne precautions. Transmission-based precautions are used when the route(s) of transmission is (are) not completely interrupted using standard precautions alone. Some diseases, such as tuberculosis, have multiple routes of transmission so more than one transmission-based precautions category must be implemented. See Table 4.2 outlining the categories of transmission precautions with associated PPE and other precautions. When possible, patients with transmission-based precautions should be placed in a single occupancy room with dedicated patient care equipment (e.g., blood pressure cuffs, stethoscope, thermometer). Transport of the patient and unnecessary movement outside the patient room should be limited. However, when transmission-based precautions are implemented, it is also important for the nurse to make efforts to counteract possible adverse effects of these precautions on patients, such as anxiety, depression, perceptions of stigma, and reduced contact with clinical staff.
Table 4.2 Transmission-Based Precautions[3]
| Precaution | Implementation | PPE and Other Precautions |
|---|---|---|
| Contact | Known or suspected infections with increased risk for contact transmission (e.g., draining wounds, fecal incontinence) or with epidemiologically important organisms, such as C-diff, MRSA, VRE, or RSV |
Note: Use only soap and water for hand hygiene in patients with C. difficile infection. |
| Enhanced barrier | Used during high-contact resident care activities for individuals colonized or infected with a multidrug-resistant organism (MDRO), as well as those at increased risk of MDRO acquisition |
|
| Droplet | Known or suspected infection with pathogens transmitted by large respiratory droplets generated by coughing, sneezing, or talking, such as influenza, coronavirus, or pertussis |
|
| Airborne | Known or suspected infection with pathogens transmitted by small respiratory droplets, such as measles, tuberculosis, and disseminated herpes zoster | Fit-tested N-95 respirator or PAPR
|
View a list of transmission-based precautions used for specific medical conditions at the CDC Guideline for Isolation Precautions.
Patient Transport
Several principles are used to guide transport of patients requiring transmission-based precautions. In the inpatient and residential settings, these principles include the following:
- Limiting transport for essential purposes only, such as diagnostic and therapeutic procedures that cannot be performed in the patient’s room
- Using appropriate barriers on the patient consistent with the route and risk of transmission (e.g., mask, gown, covering the affected areas when infectious skin lesions or drainage is present)
- Notify other health care personnel involved in the care of the patient of the transmission-based precautions. For example, when transporting the patient to radiology, inform the radiology technician of the precautions.[4]
Appropriate Hand Hygiene
Hand hygiene is the single most important practice to reduce the transmission of infectious agents in health care settings and is an essential element of standard precautions.[5] Routine handwashing during appropriate moments is a simple and effective way to prevent infection. However, it is estimated that health care professionals, on average, properly clean their hands less than 50% of the time it is indicated.[6] The Joint Commission, the organization that sets evidence-based standards of care for hospitals, recently updated its hand hygiene standards in 2018 to promote enforcement. If a Joint Commission surveyor witnesses an individual failing to properly clean their hands when it is indicated, a deficiency will be cited requiring improvement by the agency. This deficiency could potentially jeopardize a hospital’s accreditation status and their ability to receive payment for patient services. Therefore, it is essential for all health care workers to ensure they are using proper hand hygiene at the appropriate times.[7]
There are several evidence-based guidelines for performing appropriate hand hygiene. These guidelines include frequency of performing hand hygiene according to the care circumstances, solutions used, and technique performed. The Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends health care personnel perform hand hygiene at specific times when providing care to patients. These moments are often referred to as the “Moments for Hand Hygiene.”[8] See Figures 4.1[9] and 4.2[10] for an illustration and application of the five moments of hand hygiene. The five moments of hand hygiene are as follows:
- Immediately before touching a patient
- Before performing an aseptic task or handling invasive devices
- Before moving from a soiled body site to a clean body site on a patient
- After touching a patient or their immediate environment
- After contact with blood, body fluids, or contaminated surfaces (with or without glove use)
When performing hand hygiene, washing with soap and water, or an approved alcohol-based hand rub solution that contains at least 60% alcohol, may be used. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of improved compliance. Handrubs are also preferred because they are generally less irritating to health care worker’s hands. However, it is important to recognize that alcohol-based rubs do not eliminate some types of germs, such as Clostridium difficile (C-diff).
When using the alcohol-based handrub method, the CDC recommends the following steps. See Figure 4.3[11] for a handrub poster created by the World Health Organization.
- Apply product to the palm of one hand in an amount that will cover all surfaces.
- Rub hands together, covering all the surfaces of the hands, fingers, and wrists until the hands are dry. Surfaces include the palms and fingers, between the fingers, the backs of the hands and fingers, the fingertips, and the thumbs.
- The process should take about 20 seconds, and the solution should be dry.[12]
When washing with soap and water, the CDC recommends using the following steps. See Figure 4.4[13] for an image of a handwashing poster created by the World Health Organization.
- Wet hands with warm or cold running water and apply facility-approved soap.
- Lather hands by rubbing them together with the soap. Use the same technique as the handrub process to clean the palms and fingers, between the fingers, the backs of the hands and fingers, the fingertips, and the thumbs.
- Scrub thoroughly for at least 20 seconds.
- Rinse hands well under clean, running water.
- Dry the hands using a clean towel or disposable toweling.
- Use a clean paper towel to shut off the faucet.[14]
By performing hand hygiene at the proper moments and using appropriate techniques, you will ensure your hands are safe and you are not transmitting infectious organisms to yourself or others.
Hand Hygiene for Healthcare Workers on YouTube[15]
Personal Protective Equipment (PPE)
Personal protective equipment (PPE) includes gloves, gowns, face shields, goggles, and masks used to prevent the spread of infection to and from patients and health care providers. Depending on the anticipated exposure, PPE may include the use of gloves, a fluid-resistant gown, goggles or a face shield, and a mask or respirator. When used for a patient with transmission-based precautions, PPE supplies are typically stored in an isolation cart next to the patient’s room, and a card is posted on the door alerting staff and visitors to precautions needed before entering the room.
Gloves
Gloves protect both patients and health care personnel from exposure to infectious material that may be carried on the hands. Gloves are used to prevent contamination of health care personnel hands during activities such as the following:
- Anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin, and other potentially infectious material
- Having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route, such as Vancomycin-resistant enterococci (VRE), Methicillin-resistant staphylococcus aureus (MRSA), and Respiratory syncytial virus (RSV)
- Handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces[16]
Nonsterile disposable medical gloves for routine patient care are made of a variety of materials, such as latex, vinyl, and nitrile. Many people are allergic to latex, so be sure to check for latex allergies for the patient and other health care professionals. See Figure 4.5[17] for an image of nonsterile medical gloves in various sizes in a health care setting. At times, gloves may need to be changed when providing care to a single patient to prevent cross-contamination of body sites. It is also necessary to change gloves if the patient interaction requires touching portable computer keyboards or other mobile equipment that is transported from room to room. Discarding gloves between patients is necessary to prevent transmission of infectious material. Gloves must not be washed for subsequent reuse because microorganisms cannot be reliably removed from glove surfaces, and continued glove integrity cannot be ensured.[18]
When gloves are worn in combination with other PPE, they are put on last. Gloves that fit snugly around the wrist should be used in combination with isolation gowns because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands.
Gloves should be removed properly to prevent contamination. See Figure 4.6[19] for an illustration of properly removing gloves. Hand hygiene should be performed following glove removal to ensure the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or contaminated the hands during glove removal. One method for properly removing gloves includes the following steps:
- Grasp the outside of one glove near the wrist. Do not touch your skin.
- Peel the glove away from your body, pulling it inside out.
- Hold the removed glove in your gloved hand.
- Put your fingers inside the glove at the top of your wrist and peel off the second glove.
- Turn the second glove inside out while pulling it away from your body, leaving the first glove inside the second.
- Dispose of the gloves safely. Do not reuse.
- Perform hand hygiene immediately after removing the gloves.[20]
Gowns
Isolation gowns are used to protect the health care worker’s arms and exposed body areas and to prevent contamination of their clothing with blood, body fluids, and other potentially infectious material. Isolation gowns may be disposable or washable/reusable. See Figure 4.7[21] for an image of a nurse wearing an isolation gown along with goggles and a respirator. When using standard precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when contact transmission-based precautions are in place, donning of both gown and gloves upon room entry is indicated to prevent unintentional contact of clothing with contaminated environmental surfaces.
Gowns are usually the first piece of PPE to be donned. Isolation gowns should be removed before leaving the patient room to prevent possible contamination of the environment outside the patient’s room. Isolation gowns should be removed in a manner that prevents contamination of clothing or skin. The outer, “contaminated,” side of the gown is turned inward and rolled into a bundle, and then it is discarded into a designated container to contain contamination. See more information about putting on and removing PPE in the subsection below.[22]
Masks
The mucous membranes of the mouth, nose, and eyes are susceptible portals of entry for infectious agents. Masks are used to protect these sites from entry of large infectious droplets. See Figure 4.8[23] for an image of nurse wearing a surgical mask. Masks have three primary purposes in health care settings:
- Used by health care personnel to protect them from contact with infectious material from patients (e.g., respiratory secretions and sprays of blood or body fluids), consistent with standard precautions and droplet transmission precautions
- Used by health care personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents potentially carried in a health care worker’s mouth or nose
- Placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others in public areas (i.e., respiratory hygiene)[24]
Masks may be used in combination with goggles or a face shield to provide more complete protection for the face. Masks should not be confused with respirators used during airborne transmission-based precautions to prevent inhalation of small, aerosolized infectious droplets.[25]
It is important to properly wear and remove masks to avoid contamination. See Figure 4.9[26] for CDC face mask recommendations for health care personnel.
Goggles/Face Shields
Eye protection chosen for specific work situations (e.g., goggles or face shields) depends upon the circumstances of exposure, other PPE used, and personal vision needs. Personal eyeglasses are not considered adequate eye protection. See Figure 4.10[27] for an image of a health care professional wearing a face shield along with a N95 respirator.
Respirators and PAPRs
Respiratory protection used during airborne transmission precautions requires the use of special equipment. Traditionally, a fitted respirator mask with N95 or higher filtration has been worn by health care professionals to prevent inhalation of small airborne infectious particles. A user-seal check (formerly called a “fit check”) should be performed by the wearer of a respirator each time a respirator is donned to minimize air leakage around the facepiece.
A newer piece of equipment used for respiratory protection is the powered air-purifying respirator (PAPR). A PAPR is an air-purifying respirator that uses a blower to force air through filter cartridges or canisters into the breathing zone of the wearer. This process creates an air flow inside either a tight-fitting facepiece or loose-fitting hood or helmet, providing a higher level of protection against aerosolized pathogens, such as COVID-19, than a N95 respirator. See Figure 4.11[28] for an example of PAPR in use.
The CDC currently recommends N95 or higher level respirators for personnel exposed to patients with suspected or confirmed tuberculosis and other airborne diseases, especially during aerosol-generating procedures such as respiratory-tract suctioning.[29] It is important to apply, wear, and remove respirators appropriately to avoid contamination. See Figure 4.12[30] for CDC recommendations when wearing disposable respirators.
How to Put On (Don) PPE Gear
Follow agency policy for donning PPE according to transmission-based precautions. More than one donning method for putting on PPE may be acceptable. The CDC recommends the following steps for donning PPE[31]:
- Identify and gather the proper PPE to don. Ensure the gown size is correct.
- Perform hand hygiene using hand sanitizer or wash hands with soap and water.
- Put on the isolation gown. Tie all of the ties on the gown. Assistance may be needed by other health care personnel to tie back ties.
- Based on specific transmission-based precautions and agency policy, put on a mask or N95 respirator. The top strap should be placed on the crown (top) of the head, and the bottom strap should be at the base of the neck. If the mask has loops, hook them appropriately around your ears. Masks and respirators should extend under the chin, and both your mouth and nose should be protected. Perform a user-seal check each time you put on a respirator. If the respirator has a nosepiece, it should be fitted to the nose with both hands, but it should not be bent or tented. Masks typically require the nosepiece to be pinched to fit around the nose, but do not pinch the nosepiece of a respirator with one hand. Do not wear a respirator or mask under your chin or store it in the pocket of your scrubs between patients.
- Put on a face shield or goggles when indicated. When wearing an N95 respirator with eye protection, select eye protection that does not affect the fit or seal of the respirator and one that does not affect the position of the respirator. Goggles provide excellent protection for the eyes, but fogging is common. Face shields provide full-face coverage.
- Put on gloves. Gloves should cover the cuff (wrist) of the gown.
- You may now enter the patient’s room.
How to Take Off (Doff) PPE Gear
More than one doffing method for removing PPE may be acceptable. Train using your agency’s procedure, and practice until you have successfully mastered the steps to avoid contamination of yourself and others. There are established cases of nurses dying from disease transmitted during incorrect removal of PPE. Below are sample steps of doffing established by the CDC[34]:
- Remove the gloves. Ensure glove removal does not cause additional contamination of the hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
- Remove the gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied; do so in a gentle manner and avoid a forceful movement. Reach up to the front of your shoulders and carefully pull the gown down and away from your body. Rolling the gown down is also an acceptable approach. Dispose of the gown in a trash receptacle. If it is a washable gown, place it in the specified laundry bin for PPE in the room.
- Health care personnel may now exit the patient room.
- Perform hand hygiene.
- Remove the face shield or goggles. Carefully remove the face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of the face shield or goggles.
- Remove and discard the respirator or face mask. Do not touch the front of the respirator or face mask. Remove the bottom strap by touching only the strap and bringing it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. For masks, carefully untie (or unhook ties from the ears) and pull the mask away from your face without touching the front.
- Perform hand hygiene after removing the respirator/mask. If your workplace is practicing reuse, perform hand hygiene before putting it on again.
View a YouTube Video from the CDC on Putting on PPE[35]
View a YouTube Video from the CDC on Removing PPE[36]
Respiratory Hygiene
Respiratory hygiene is targeted at patients, accompanying family members and friends, and health care workers with undiagnosed transmissible respiratory infections. It applies to any person with signs of illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a health care facility. See Figure 4.13[37] for an example of a “Cover Your Cough” poster used in public areas to promote respiratory hygiene. The elements of respiratory hygiene include the following:
- Education of health care facility staff, patients, and visitors
- Posted signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends
- Source control measures for a coughing person (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, or applying surgical masks on the coughing person to contain secretions)
- Hand hygiene after contact with one’s respiratory secretions
- Spatial separation, ideally greater than 3 feet, of persons with respiratory infections in common waiting areas when possible.[38]
Health care personnel are advised to wear a mask and use frequent hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Health care personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients. If this is not possible, then a mask should be worn while providing patient care.[39]
Environmental Measures
Routine cleaning and disinfecting surfaces in patient-care areas are part of standard precautions. The cleaning and disinfecting of all patient-care areas are important for frequently touched surfaces, especially those closest to the patient that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces, and equipment in close proximity to the patient).
Medical equipment and instruments/devices must also be cleaned to prevent patient-to-patient transmission of infectious agents. For example, stethoscopes should be cleaned before and after use for all patients. Patients who have transmission-based precautions should have dedicated medical equipment that remains in their room (e.g., stethoscope, blood pressure cuff, thermometer). When dedicated equipment is not possible, such as a unit-wide bedside blood glucose monitor, disinfection after each patient’s use should be performed according to agency policy.[40]
Disposal of Contaminated Waste
Medical waste requires careful disposal according to agency policy. The Occupational Safety and Health Administration (OSHA) has established measures for discarding regulated medical waste items to protect the workers who generate medical waste, as well as those who manage the waste from point of generation to disposal. Contaminated waste is placed in a leak-resistant biohazard bag, securely closed, and placed in a labeled, leakproof, puncture-resistant container in a storage area. Sharps containers are used to dispose of sharp items such as discarded tubes with small amounts of blood, scalpel blades, needles, and syringes.[41]
Sharps Safety
Injuries due to needles and other sharps have been associated with transmission of blood-borne pathogens (BBP), including hepatitis B, hepatitis C, and HIV to health care personnel. The prevention of sharps injuries is an essential element of standard precautions and includes measures to handle needles and other sharp devices in a manner that will prevent injury to the user and to others who may encounter the device during or after a procedure. The Bloodborne Pathogens Standard is a regulation that prescribes safeguards to protect workers against health hazards related to blood-borne pathogens. It includes work practice controls, hepatitis B vaccinations, hazard communication and training, plans for when an employee is exposed to a BBP, and recordkeeping.
When performing procedures that include needles or other sharps, dispose of these items immediately in FDA-cleared sharps disposal containers. Additionally, to prevent needlestick injuries, needles and other contaminated sharps should not be recapped. See Figure 4.14[42] for an image of a sharps disposal container. FDA-cleared sharps disposal containers are made from rigid plastic and come marked with a line that indicates when the container should be considered full, which means it’s time to dispose of the container. When a sharps disposal container is about three-quarters full, follow agency policy for proper disposal of the container.
If you are stuck by a needle or other sharps or are exposed to blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water. Report the incident immediately to your instructor or employer and seek immediate medical attention according to agency and school policy.
Textiles and Laundry
Soiled textiles, including bedding, towels, and patient or resident clothing may be contaminated with pathogenic microorganisms. However, the risk of disease transmission is negligible if they are handled, transported, and laundered in a safe manner. Follow agency policy for handling soiled laundry using standard precautions. Key principles for handling soiled laundry are as follows:
- Do not shake items or handle them in any way that may aerosolize infectious agents.
- Avoid contact of one’s body and personal clothing with the soiled items being handled.
- Place soiled items in a laundry bag or designated bin in the patient’s room before transporting to a laundry area. When laundry chutes are used, they must be maintained to minimize dispersion of aerosols from contaminated items.[43]
Media Attributions
- 5Moments_Image
- handrub
- how to handrub
- how to handwash
- 2448px-Surgery_Centre_Accriditation
- poster-how-to-remove-gloves
- U.S. Navy Doctors, Nurses and Corpsmen Treat COVID Patients in the ICU Aboard USNS Comfort
- USNS Comfort (T-AH 20) Performs Surgery
- fs-facemask-dos-donts
- 15650272810_b88259cdbd_k
- PAPRs_in_use_01
- fs-respirator-on-off
- cycphceng
- Sharps-Containers
- Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
- Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Centers for Disease Control and Prevention. (2019, April 29). Hand hygiene in healthcare settings. https://www.cdc.gov/handhygiene/ ↵
- The Joint Commission. (n.d.). Update: Citing observations of hand hygiene noncompliance. https://www.jointcommission.org/-/media/tjc/documents/standards/jc-requirements/ambulatory-care/2018/update_citing_observations_of_hand_hygiene_noncompliancepdf.pdf?db=web&hash=F89BFFFAEDA700CC2E667049D8F542B2 ↵
- World Health Organization. (n.d.). My 5 moments of hand hygiene. https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ ↵
- “5Moments_Image.gif” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ ↵
- This work is derived from “Hand_Hygiene_When_and_How_Leaflet.pdf” by World Health Organization and is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www.who.int/infection-prevention/tools/hand-hygiene/workplace_reminders/en/ ↵
- This work is derived from “Hand_Hygiene_When_and_How_Leaflet.pdf” by World Health Organization and is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www.who.int/infection-prevention/tools/hand-hygiene/workplace_reminders/en/ ↵
- Centers for Disease Control and Prevention. (2019, April 29). Hand hygiene in healthcare settings. https://www.cdc.gov/handhygiene/ ↵
- “How_To_HandWash_Poster.pdf” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ ↵
- Centers for Disease Control and Prevention. (2019, April 29). Hand hygiene in healthcare settings. https://www.cdc.gov/handhygiene/ ↵
- RegisteredNurseRN. (2018, December 1). Hand hygiene for healthcare workers | Hand washing soap and water technique nursing skill [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/G5-Rp-6FMCQ ↵
- Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
- “Surgery Centre Accriditation.jpg” by Accredia is licensed under CC BY-SA 4.0 ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- “poster-how-to-remove-gloves.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www.cdc.gov/vhf/ebola/resources/posters.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- “U.S. Navy Doctors, Nurses and Corpsmen Treat COVID Patients in the ICU Aboard USNS Comfort (49825651378).jpg” by Navy Medicine is in the Public Domain. ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- “USNS Comfort (T-AH 20) Performs Surgery (49803007781).jpg” by Navy Medicine is in the Public Domain. ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- “fs-facemask-dos-donts.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html ↵
- “Checking Personal Protective Equipment (PPE) in the fight against Ebola” by DFID - UK Department for International Development is licensed under CC BY 2.0 ↵
- “PAPRs_in_use_01.jpg" by Ca.garcia.s is licensed under CC BY-SA 4.0 ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- “fs-respirator-on-off.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html ↵
- Centers for Disease Control and Prevention. (2020, August 19). Using personal protective equipment (PPE). https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html ↵
- RegisteredNurseRN. (2020, May 11). N95 mask - How to wear | N95 respirator nursing skill tutorial [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/i-uD8rUwG48 ↵
- RegisteredNurseRN. (2020, May 29). PPE training video: Donning and doffing PPE nursing skill [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/iwvnA_b9Q8Y ↵
- Centers for Disease Control and Prevention. (2020, August 19). Using personal protective equipment (PPE). https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html ↵
- Centers for Disease Control and Prevention. (2020, July 14). Demonstration of donning (putting on) personal protective equipment (PPE) [Video]. YouTube. All rights reserved. https://youtu.be/H4jQUBAlBrI ↵
- Centers for Disease Control and Prevention. (2020, April 21). Demonstration of doffing (taking off) personal protective equipment (PPE) [Video]. YouTube. All rights reserved. https://youtu.be/PQxOc13DxvQ ↵
- “cycphceng.pdf” by https://www.health.state.mn.us/index.html is in the Public Domain. ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
- Centers for Disease Control and Prevention. (2015, November 5). Background I. Regulated medical waste. https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/medical-waste.html#i3 ↵
- “Sharps-Containers.jpg” by Federal Drug Administration (FDA) is in the Public Domain. Access for free at https://www.fda.gov/medical-devices/safely-using-sharps-needles-and-syringes-home-work-and-travel/sharps-disposal-containers ↵
- Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
The integumentary system includes the skin, hair, and nails. The skin is an organ that performs a variety of essential functions, such as protecting the body from invasion by microorganisms, chemicals, and other environmental factors; preventing dehydration; acting as a sensory organ; modulating body temperature and electrolyte balance; and synthesizing vitamin D.[1]
Skin
The skin is made of multiple layers of cells and tissues, which are held to underlying structures by connective tissue. See Figure 14.1[2] for an image of the layers of the skin. The skin is composed of two main layers: the uppermost thin layer called the epidermis made of closely packed epithelial cells, and the inner thick layer called the dermis that houses blood vessels, hair follicles, sweat glands, and nerve fibers. Beneath the dermis lies the hypodermis that contains connective tissue and adipose tissue (stored fat) to connect the skin to the underlying bones and muscles. The skin acts as a sense organ because the epidermis, dermis, and hypodermis contain specialized sensory nerve structures that detect touch, surface temperature, and pain.[3]
The color of skin is created by pigments, including melanin, carotene, and hemoglobin. Melanin is produced by cells called melanocytes that are scattered throughout the epidermis. See Figure 14.2[4] for an illustration of melanin and melanocytes. When there is an irregular accumulation of melanocytes in the skin, freckles appear. Dark-skinned individuals produce more melanin than those with pale skin. Exposure to the UV rays of the sun or a tanning bed causes additional melanin to be manufactured and built up, resulting in the darkening of the skin referred to as a tan. Increased melanin accumulation protects the DNA of epidermal cells from UV ray damage, but it requires about ten days after initial sun exposure for melanin synthesis to peak. This is why pale-skinned individuals often suffer sunburns during initial exposure to the sun. Darker-skinned individuals can also get sunburns, but they are more protected from their existing melanin than pale-skinned individuals.[5]
Too much sun exposure can eventually lead to wrinkling due to the destruction of the cellular structure of the skin, and in severe cases, can cause DNA damage resulting in skin cancer. Moles are larger masses of melanocytes, and although most are benign, they should be monitored for changes that indicate the presence of skin cancer. See Figure 14.3[6] for an image of moles.
Patients are encouraged to use the ABCDE mnemonic to watch for signs of early-stage melanoma developing in moles. Consult a health care provider if you find these signs of melanoma when assessing a patient’s skin:
- Asymmetrical: The sides of the moles are not symmetrical
- Borders: The edges of the mole are irregular in shape
- Color: The color of the mole has various shades of brown or black
- Diameter: The mole is larger than 6 mm (0.24 in)
- Evolving: The shape of the mole has changed
Hair
Hair is made of dead, keratinized cells that originate in the hair follicle in the dermis. For these reasons, there is no sensation in hair. See Figure 14.4[7] for an image of a hair follicle. Hair serves a variety of functions, including protection, sensory input, thermoregulation, and communication. For example, hair on the head protects the skull from the sun. Hair in the nose, ears, and around the eyes (eyelashes) defends the body by trapping any dust particles that may contain allergens and microbes. Hair of the eyebrows prevents sweat and other particles from dripping into the eyes.
Hair also has a sensory function due to sensory innervation by a hair root plexus surrounding the base of each hair follicle. Hair is extremely sensitive to air movement or other disturbances in the environment, even more so than the skin surface. This feature is also useful for the detection of the presence of insects or other potentially damaging substances on the skin surface. Each hair root is also connected to a smooth muscle called the arrector pili that contracts in response to nerve signals from the sympathetic nervous system, making the external hair shaft “stand up.” This movement is commonly referred to as goose bumps. The primary purpose for this movement is to trap a layer of air to add insulation.[8]
Nails
The nail bed is a specialized structure of the epidermis that is found at the tips of our fingers and toes. See Figure 14.5[9] for an illustration of a fingernail. The nail body is formed on the nail bed and protects the tips of our fingers and toes as they experience mechanical stress while being used. In addition, the nail body forms a back-support for picking up small objects with the fingers.[10]
Sweat Glands
When the body becomes warm, sweat glands produce sweat to cool the body. There are two types of sweat glands that secrete slightly different products. An eccrine sweat gland produces hypotonic sweat for thermoregulation. See Figure 14.6[11] for an illustration of an eccrine sweat gland. These glands are found all over the skin’s surface but are especially abundant on the palms of the hand, the soles of the feet, and the forehead. They are coiled glands lying deep in the dermis, with the duct rising up to a pore on the skin surface where the sweat is released. This type of sweat is composed mostly of water and some salt, antibodies, traces of metabolic waste, and dermcidin, an antimicrobial peptide. Eccrine glands are a primary component of thermoregulation and help to maintain homeostasis.[12]
Apocrine sweat glands are mostly found in hair follicles in densely hairy areas, such as the armpits and genital regions. In addition to secreting water and salt, apocrine sweat includes organic compounds that make the sweat thicker and subject to bacterial decomposition and subsequent odor. The release of this sweat is controlled by the nervous system and hormones and plays a role in the human pheromone response. Most commercial antiperspirants use an aluminum-based compound as their primary active ingredient to stop sweat. When the antiperspirant enters the sweat gland duct, the aluminum-based compounds form a physical block in the duct, which prevents sweat from coming out of the pore.[13]
Skin Lesions
A lesion is an area of abnormal tissue. There are many terms for common skin lesions that may be described in a patient’s chart. These terms are defined in Table 14.2. See Figure 14.7[14] for illustrations of common skin lesions.
Table 14.2 Medical Terms Associated with Skin Lesions and Rashes[15]
| Medical Term | Definition |
|---|---|
| abscess | localized collection of pus |
| bulla (pl., bullae) | fluid-filled blister no more than 5 mm in diameter |
| carbuncle | deep, pus-filled abscess generally formed from multiple furuncles |
| crust | dried fluids from a lesion on the surface of the skin |
| cyst | encapsulated sac filled with fluid, semi-solid matter, or gas, typically located just below the upper layers of skin |
| folliculitis | a localized rash due to inflammation of hair follicles |
| furuncle (boil) | pus-filled abscess due to infection of a hair follicle |
| macules | smooth spots of discoloration on the skin |
| papules | small, raised bumps on the skin, such as a mosquito bite |
| pseudocyst | lesion that resembles a cyst but with a less-defined boundary |
| purulent | pus-producing; also called suppurative |
| pustules | fluid- or pus-filled bumps on the skin, such as acne |
| pyoderma | any suppurative (pus-producing) infection of the skin |
| suppurative | producing pus; purulent |
| ulcer | break in the skin or open sore such as a venous ulcer |
| vesicle | small, fluid-filled lesion, such as a herpes blister |
| wheal | swollen, inflamed skin that itches or burns, often from an allergic reaction |
The integumentary system includes the skin, hair, and nails. The skin is an organ that performs a variety of essential functions, such as protecting the body from invasion by microorganisms, chemicals, and other environmental factors; preventing dehydration; acting as a sensory organ; modulating body temperature and electrolyte balance; and synthesizing vitamin D.[16]
Skin
The skin is made of multiple layers of cells and tissues, which are held to underlying structures by connective tissue. See Figure 14.1[17] for an image of the layers of the skin. The skin is composed of two main layers: the uppermost thin layer called the epidermis made of closely packed epithelial cells, and the inner thick layer called the dermis that houses blood vessels, hair follicles, sweat glands, and nerve fibers. Beneath the dermis lies the hypodermis that contains connective tissue and adipose tissue (stored fat) to connect the skin to the underlying bones and muscles. The skin acts as a sense organ because the epidermis, dermis, and hypodermis contain specialized sensory nerve structures that detect touch, surface temperature, and pain.[18]
The color of skin is created by pigments, including melanin, carotene, and hemoglobin. Melanin is produced by cells called melanocytes that are scattered throughout the epidermis. See Figure 14.2[19] for an illustration of melanin and melanocytes. When there is an irregular accumulation of melanocytes in the skin, freckles appear. Dark-skinned individuals produce more melanin than those with pale skin. Exposure to the UV rays of the sun or a tanning bed causes additional melanin to be manufactured and built up, resulting in the darkening of the skin referred to as a tan. Increased melanin accumulation protects the DNA of epidermal cells from UV ray damage, but it requires about ten days after initial sun exposure for melanin synthesis to peak. This is why pale-skinned individuals often suffer sunburns during initial exposure to the sun. Darker-skinned individuals can also get sunburns, but they are more protected from their existing melanin than pale-skinned individuals.[20]
Too much sun exposure can eventually lead to wrinkling due to the destruction of the cellular structure of the skin, and in severe cases, can cause DNA damage resulting in skin cancer. Moles are larger masses of melanocytes, and although most are benign, they should be monitored for changes that indicate the presence of skin cancer. See Figure 14.3[21] for an image of moles.
Patients are encouraged to use the ABCDE mnemonic to watch for signs of early-stage melanoma developing in moles. Consult a health care provider if you find these signs of melanoma when assessing a patient’s skin:
- Asymmetrical: The sides of the moles are not symmetrical
- Borders: The edges of the mole are irregular in shape
- Color: The color of the mole has various shades of brown or black
- Diameter: The mole is larger than 6 mm (0.24 in)
- Evolving: The shape of the mole has changed
Hair
Hair is made of dead, keratinized cells that originate in the hair follicle in the dermis. For these reasons, there is no sensation in hair. See Figure 14.4[22] for an image of a hair follicle. Hair serves a variety of functions, including protection, sensory input, thermoregulation, and communication. For example, hair on the head protects the skull from the sun. Hair in the nose, ears, and around the eyes (eyelashes) defends the body by trapping any dust particles that may contain allergens and microbes. Hair of the eyebrows prevents sweat and other particles from dripping into the eyes.
Hair also has a sensory function due to sensory innervation by a hair root plexus surrounding the base of each hair follicle. Hair is extremely sensitive to air movement or other disturbances in the environment, even more so than the skin surface. This feature is also useful for the detection of the presence of insects or other potentially damaging substances on the skin surface. Each hair root is also connected to a smooth muscle called the arrector pili that contracts in response to nerve signals from the sympathetic nervous system, making the external hair shaft “stand up.” This movement is commonly referred to as goose bumps. The primary purpose for this movement is to trap a layer of air to add insulation.[23]
Nails
The nail bed is a specialized structure of the epidermis that is found at the tips of our fingers and toes. See Figure 14.5[24] for an illustration of a fingernail. The nail body is formed on the nail bed and protects the tips of our fingers and toes as they experience mechanical stress while being used. In addition, the nail body forms a back-support for picking up small objects with the fingers.[25]
Sweat Glands
When the body becomes warm, sweat glands produce sweat to cool the body. There are two types of sweat glands that secrete slightly different products. An eccrine sweat gland produces hypotonic sweat for thermoregulation. See Figure 14.6[26] for an illustration of an eccrine sweat gland. These glands are found all over the skin’s surface but are especially abundant on the palms of the hand, the soles of the feet, and the forehead. They are coiled glands lying deep in the dermis, with the duct rising up to a pore on the skin surface where the sweat is released. This type of sweat is composed mostly of water and some salt, antibodies, traces of metabolic waste, and dermcidin, an antimicrobial peptide. Eccrine glands are a primary component of thermoregulation and help to maintain homeostasis.[27]
Apocrine sweat glands are mostly found in hair follicles in densely hairy areas, such as the armpits and genital regions. In addition to secreting water and salt, apocrine sweat includes organic compounds that make the sweat thicker and subject to bacterial decomposition and subsequent odor. The release of this sweat is controlled by the nervous system and hormones and plays a role in the human pheromone response. Most commercial antiperspirants use an aluminum-based compound as their primary active ingredient to stop sweat. When the antiperspirant enters the sweat gland duct, the aluminum-based compounds form a physical block in the duct, which prevents sweat from coming out of the pore.[28]
Skin Lesions
A lesion is an area of abnormal tissue. There are many terms for common skin lesions that may be described in a patient’s chart. These terms are defined in Table 14.2. See Figure 14.7[29] for illustrations of common skin lesions.
Table 14.2 Medical Terms Associated with Skin Lesions and Rashes[30]
| Medical Term | Definition |
|---|---|
| abscess | localized collection of pus |
| bulla (pl., bullae) | fluid-filled blister no more than 5 mm in diameter |
| carbuncle | deep, pus-filled abscess generally formed from multiple furuncles |
| crust | dried fluids from a lesion on the surface of the skin |
| cyst | encapsulated sac filled with fluid, semi-solid matter, or gas, typically located just below the upper layers of skin |
| folliculitis | a localized rash due to inflammation of hair follicles |
| furuncle (boil) | pus-filled abscess due to infection of a hair follicle |
| macules | smooth spots of discoloration on the skin |
| papules | small, raised bumps on the skin, such as a mosquito bite |
| pseudocyst | lesion that resembles a cyst but with a less-defined boundary |
| purulent | pus-producing; also called suppurative |
| pustules | fluid- or pus-filled bumps on the skin, such as acne |
| pyoderma | any suppurative (pus-producing) infection of the skin |
| suppurative | producing pus; purulent |
| ulcer | break in the skin or open sore such as a venous ulcer |
| vesicle | small, fluid-filled lesion, such as a herpes blister |
| wheal | swollen, inflamed skin that itches or burns, often from an allergic reaction |
Now that we have reviewed the anatomy of the integumentary system and common integumentary conditions, let’s review the components of an integumentary assessment. The standard for documentation of skin assessment is within 24 hours of admission to inpatient care. Skin assessment should also be ongoing in inpatient and long-term care.[31]
A routine integumentary assessment by a registered nurse in an inpatient care setting typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill.[32]
Subjective Assessment
Begin the assessment by asking focused interview questions regarding the integumentary system. Itching is the most frequent complaint related to the integumentary system. See Table 14.4a for sample interview questions.
Table 14.4a Focused Interview Questions for the Integumentary System
| Questions | Follow-up |
|---|---|
| Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole, lump, bump, or nodule?[33] | Use the PQRSTU method to gain additional information about current symptoms. Read more about the PQRSTU method in the "Health History" chapter. |
| Have you ever been diagnosed with a condition such as acne, eczema, skin cancer, pressure injuries, jaundice, edema, or lymphedema? | Please describe. |
| Are you currently using any prescription or over-the-counter medications, creams, vitamins, or supplements to treat a skin, hair, or nail condition? | Please describe. |
Objective Assessment
There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown. Certain body areas require particular observation because they are more prone to pressure injuries, such as bony prominences, skin folds, perineum, between digits of the hands and feet, and under any medical device that can be removed during routine daily care.[34]
Inspection
Color
Inspect the color of the patient’s skin and compare findings to what is expected for their skin tone. Note a change in color such as pallor (paleness), cyanosis (blueness), jaundice (yellowness), or erythema (redness). Note if there is any bruising (ecchymosis) present.
Scalp
If the patient reports itching of the scalp, inspect the scalp for lice and/or nits.
Lesions and Skin Breakdown
Note any lesions, skin breakdown, or unusual findings, such as rashes, petechiae, unusual moles, or burns. Be aware that unusual patterns of bruising or burns can be signs of abuse that warrant further investigation and reporting according to agency policy and state regulations.
Auscultation
Auscultation does not occur during a focused integumentary exam.
Palpation
Palpation of the skin includes assessing temperature, moisture, texture, skin turgor, capillary refill, and edema. If erythema or rashes are present, it is helpful to apply pressure with a gloved finger to further assess for blanching (whitening with pressure).
Temperature, Moisture, and Texture
Fever, decreased perfusion of the extremities, and local inflammation in tissues can cause changes in skin temperature. For example, a fever can cause a patient’s skin to feel warm and sweaty (diaphoretic). Decreased perfusion of the extremities can cause the patient’s hands and feet to feel cool, whereas local tissue infection or inflammation can make the localized area feel warmer than the surrounding skin. Research has shown that experienced practitioners can palpate skin temperature accurately and detect differences as small as 1 to 2 degrees Celsius. For accurate palpation of skin temperature, do not hold anything warm or cold in your hands for several minutes prior to palpation. Use the palmar surface of your dominant hand to assess temperature.[35] While assessing skin temperature, also assess if the skin feels dry or moist and the texture of the skin. Skin that appears or feels sweaty is referred to as being diaphoretic.
Capillary Refill
The capillary refill test is a test done on the nail beds to monitor perfusion, the amount of blood flow to tissue. Pressure is applied to a fingernail or toenail until it turns white, indicating that the blood has been forced from the tissue under the nail. This whiteness is called blanching. Once the tissue has blanched, remove pressure. Capillary refill is defined as the time it takes for color to return to the tissue after pressure has been removed that caused blanching. If there is sufficient blood flow to the area, a pink color should return within 2 seconds after the pressure is removed.[36]
View the Cardiovascular Assessment Part Two | Capillary Refill Test YouTube video for a demonstration of capillary refill.[37]
Skin Turgor
Skin turgor may be included when assessing a patient’s hydration status, but research has shown it is not a good indicator. Skin turgor is the skin's elasticity. Its ability to change shape and return to normal may be decreased when the patient is dehydrated. To check for skin turgor, gently grasp skin on the patient’s lower arm between two fingers so that it is tented upwards, and then release. Skin with normal turgor snaps rapidly back to its normal position, but skin with poor turgor takes additional time to return to its normal position.[38] Skin turgor is not a reliable method to assess for dehydration in older adults because they have decreased skin elasticity, so other assessments for dehydration should be included.[39]
Edema
If edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema. See Figure 14.22[40] for an image demonstrating pitting edema. If pitting edema is present, document the depth of the indention and how long it takes for the skin to rebound back to its original position. The indentation and time required to rebound to the original position are graded on a scale from 1 to 4, where 1+ indicates a barely detectable depression with immediate rebound, and 4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound. See Figure 14.23[41] for an illustration of grading edema.
Life Span Considerations
Older Adults
Older adults have several changes associated with aging that are apparent during assessment of the integumentary system. They often have cardiac and circulatory system conditions that cause decreased perfusion, resulting in cool hands and feet. They have decreased elasticity and fragile skin that often tears more easily. The blood vessels of the dermis become more fragile, leading to bruising and bleeding under the skin. The subcutaneous fat layer thins, so it has less insulation and padding and reduced ability to maintain body temperature. Growths such as skin tags, rough patches (keratoses), skin cancers, and other lesions are more common. Older adults may also be less able to sense touch, pressure, vibration, heat, and cold.[42]
When completing an integumentary assessment, it is important to distinguish between expected and unexpected assessment findings. Please review Table 14.4b to review common expected and unexpected integumentary findings.
Table 14.4b Expected Versus Unexpected Findings on Integumentary Assessment
| Assessment | Expected Findings | Unexpected Findings (Document and notify provider if it is a new finding*) |
|---|---|---|
| Inspection | Skin is expected color for ethnicity without lesions or rashes. | Jaundice
Erythema Cyanosis Irregular-looking mole Bruising (ecchymosis) Rashes Petechiae Skin breakdown Burns |
| Auscultation | Not applicable | |
| Palpation | Skin is warm and dry with no edema. Capillary refill is less than 3 seconds. Skin has normal turgor with no tenting. | Diaphoretic or clammy
Cool extremity Edema Lymphedema Capillary refill greater than 3 seconds Tenting |
| *CRITICAL CONDITIONS to report immediately | Cool and clammy
Diaphoretic Petechiae Jaundice Cyanosis Redness, warmth, and tenderness indicating a possible infection |
Sample Documentation of Expected Findings
Skin is expected color for ethnicity without lesions or rashes. Skin is warm and dry with no edema. Capillary refill is less than 3 seconds. Normal skin turgor with no tenting.
Sample Documentation of Unexpected Findings
Mother brought the child into the clinic for evaluation of an “itchy rash around the mouth” that started about three days ago. Crusted pustules present around the patient’s mouth. Dr. Smith evaluated the patient and prescription for antibiotics provided. Mother and child educated on good hand hygiene practices to prevent spread of infection.
