Head to Toe Skin Head to Toe Skin AssessmentAssessment

Karen R. Brown BS, RN, CWS Wound/Ostomy Specialist

SKIN ASSESSMENTSSKIN ASSESSMENTS

Objectives:

Describe essentials for maintenance of healthy skin

Discuss pressure ulcer risk assessment tools

Describe appropriate documentation of skin assessment

A large amount of the dust in you home is actually dead skin

Skin Facts

Each square inch of human skin consists of twenty feet of blood vessels

Humans shed about 600,000 particles of skin every hour - about 1.5 pounds a year. By 70 years of age, an average person will have lost 105 pounds of skin.

A large amount of the dust in you home is actually dead skin

Skin Assessment

Skin assessment

important in the prevention of pressure ulcers, IAD, MADS,Intertrigo, etc.

A complete skin assessment should include:Assessing for localized heatEdemaInduration (hardness)Excessive moisture

SKIN ASSESSMENT

Skin Care is important to protect the skin from breakdown:Not massaging skinNot turning the patient back onto a still reddened surface from previous pressure loading Not vigorously rubbing skin that is at risk for skin breakdown

What tools do we use?

Eyes

Hands

Ears

excellent history taking and data gathering

Braden Scale

Nutrition Assessment Tool

Immobility/decreased mobilityImmobility/decreased mobility

CONFINED TO BED/CHAIR

Preventative Actions

Look at skin at least once a day.

Bathe only when

needed for comfort or cleanliness.

Prevent dry skin.

SKIN ASSESSMENTSKIN ASSESSMENT

For a person in a chair:

1. Change position every hour or as often as possible.

2. Use foam, gel, or air cushion to relieve pressure.

• Reduce friction by:

Lifting, rather than dragging, when repositioning.

Using cornstarch on skin.

• Involve physical therapy as needed.

NO DONUT SHAPED CUSHIONS

Donuts are for eating

Not sitting on

For a Bed Bound Patient

Change position at least every 2 hours.

Use a special mattress that contains foam, air, gel, or water.

Raise the head of bed as little and for as short as a time aspossible.

Loss of Bowel or Bladder Control

Clean skin as soon as soiled with urine or stool.• Assess and treat urine leaks.• If moisture cannot be controlled:1. Use absorbent pads and/or briefs with a quick-dryingsurface.2. Protect skin with a cream or ointment.

Poor Nutrition

Eat a balanced diet.• If a normal diet is not possible, talk to health care provider aboutfood supplements

Lowered Mental Awareness

Choose preventative actions for the person with lowered mentalawareness. For example, if the person is chair-bound, refer to thespecific preventative actions outlined in Risk Factor 1.

Support SurfacesSupport Surfaces

SKIN ASSESSMENT SKIN ASSESSMENT DOCUMENTATIONDOCUMENTATION

SKIN SKIN ASSESSMENTASSESSMENTSKIN FOLDS

DOCUMENT PRESENCE OF:

MOISTURERASHCANDIDALESIONS

2007 Medline Industries, Inc.

xerosisxerosisCaused by epidermal water loss

Loss of natural moisturization factors

LOCATION:Usually lower legsSometimes trunk and hands

Xerosis is a dermatosis exhibited as dry scaly skin with or without erythema (redness) and pruritus (itching)

xerosisxerosis

Clinically looks like

Scaling, flaking skin

Dull, white color and increased skin markings

DOCUMENTDOCUMENT changes in skin changes in skin color color excess skin excess skin moisture moisture skin turgor skin turgor changes in skin changes in skin texture texture

SKIN SKIN ASSESSMENTASSESSMENT

DOCUMENT ULCER LOCATIONS OVER BONY PROMINENCES

HISTORY OF PREVIOUS ULCERATIONS

SKIN ASSESSMENTSKIN ASSESSMENT

PALPATE FOR WARMTH, TENDERNESS,BOGGINESSEDEMA DOCUMENT EVERY DETAIL

ASSESS MEDICAL ASSESS MEDICAL DEVICES DEVICES

DOCUMENT

TYPE OF DEVICELOCATION TYPE OF SECUREMENT DEVICE

ASSESS MEDICAL ASSESS MEDICAL DEVICESDEVICES

TUBE SITE EROSION

HYPERGRANULATION TISSUE

BARIATRIC BARIATRIC SKIN SKIN ASSESSMENTASSESSMENTincontinence-related dermatitis secondary to inability to perform personal hygiene,pressure ulcers (including sites other than bony prominences), venousInsufficiency/ulceration, and/or lymphedema.

BARIATRIC SKIN BARIATRIC SKIN ASSESSMENTASSESSMENT

The bariatric patient may not be able to clean the perineal area well enough or maybe not at all.

BARIATRIC SKIN BARIATRIC SKIN ASSESSMENTASSESSMENT

Pressure ulcers not over bony prominences

Increased propensity for venous ulcers with or without lymphedema

Malnourishment

INCONTINENCE INCONTINENCE ASSOCIATED ASSOCIATED DERMATITIS (IAD)DERMATITIS (IAD)

Incontinence-associated dermatitis is a common problem affecting as many as half of the patients with urinary or fecal incontinence who are managed with absorptiveproducts.

SKIN CARE PROTOCOLSSKIN CARE PROTOCOLS

Clean after soiling and at routine intervals Avoid hot water

Use mild cleansers non- irritating and non-drying agents

Use moisturizers for dry skin Use barrier ointments/ sprays

Powder bedpans

SKIN CARE PROTOCOLSKIN CARE PROTOCOL Use heel/elbow protectors or socks

Use lift sheets or pads to move patient Limit head elevation to 30 degrees and use knee gatch if available Use overhead trapeze (prevent dragging patient up in bed) Use footboards Use light weight clothing and covers (layering is best) Minimize environmental factors leading to drying such as low humidity/exposure to cold

References References

Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care.2002;15:170-179.

Ghadially R. Aging and the epidermal permeability barrier: implications for contact dermatitis. Am J Contact Dermat. 1998;9(3):162-169. Brown DS. Perineal dermatitis risk factors: clinical validation of a conceptual framework. Ostomy Wound Manag.1995;41(10):46-48, 50, 52-53. European Pressure Ulcer Advisory Panel and National Pressure Ulcer. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.

ReferencesReferences

Portable Instructional Education (PIE). Home Health Care 1st Edition. (CD) Wound Ostomy and Continence Nurses Society, WOCN National Office, Mt. Laurel, NJ; 2008.