Foundations of Nursing - Musculoskeletal and Skin Assessment

What should be assessed in health history related to skin and mobility?

Recent changes in skin, existing wounds/lesions, activity and mobility, nutrition, pain, and elimination status.

How should skin be assessed?

inspection and palpation, systematically - head to toe, include bony prominences, on admission and at regular intervals

How often should skin assessments be performed in different settings?

-Acute Care; every shift.

-Long Term; weekly, for 4 weeks then quarterly

-Home Health; each visit

What are the three main layers of the skin?

Epidermis, dermis, and subcutaneous tissue.

What is the epidermis?

To act as a protective waterproof layer of keratin. Cells have no blood vessels of their own. Regenerates easily and quickly.

What is the dermis?

Elastic tissue made primarily of collagen. Nerves, hair follicles, glands, immune cells, and blood vessels.

What is the subcutaneous?

anchors the skin layers to underlying tissues.

What factors affect skin integrity?

Unbroken and health, age, underlying tissues, illness, nutrition, hydration, and circulation.

What changes occur in the skin as a person ages?

The maturation of epidermal cells is prolonged, leading to thinner, more easily damaged skin. In older adults, circulation and collagen formation is impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

What are the causes of skin alterations?

Being very thin or obese, fluid loss during illness, jaundice, and diseases like eczema and psoriasis.

What are the types of wounds?

Intentional, unintentional, neuropathic, vascular, pressure-related, device-related, open, closed, acute, chronic, partial thickness, full thickness, and complex.

What is a device-related injury?

Any harm caused by a medical device during care, typically resulting from prolonged pressure, friction, or shear. These are typically skin injuries but can include other types of trauma, such as nerve damage, burns, or infections.

What are some examples of device-related injuries?

Skin breakdown from oxygen tubing, IV catheters, CPAP masks, neck collars, and endotracheal tubes.

What distinguishes device-related injuries from pressure injuries?

Device-related injuries are caused by medical devices and often correspond to the shape of the device, while pressure injuries are caused by sustained pressure on bony prominences.

What are the principles of wound healing?

Intact skin is the first line of defense, hand hygiene is essential, adequate blood supply is necessary, wounds should be free from foreign material, and proper nutrition supports healing.

What factors contribute to pressure injury development?

Aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, altered consciousness, spinal cord and brain injuries, and neuromuscular disorders.

What is a pressure injury?

HAPI; healthcare-acquired pressure injury can be a pressure ulcer, decubitus, decubiti, bedsore. Pressure is usually the cause, from the pts own body weight.

What mechanisms contribute to pressure injury development?

External pressure compressing blood vessels, friction or shearing forces injuring blood vessels, and microclimate conditions like temperature and moisture.

What is the definition of a pressure injury?

A localized injury to the skin and/or underlying tissue, usually over a bony prominence, due to pressure or pressure in combination with shear.

What are the recommended repositioning intervals for patients in bed?

Every 2-3 hours.

What is the significance of nutrition and hydration in preventing pressure injuries?

Adequate nutrition and hydration are essential for maintaining skin integrity and preventing breakdown.

What are the different positions that can affect pressure points?

Supine, Fowler's (Low, Semi, Standard, High), prone, lateral, Sims', Trendelenburg, and reverse Trendelenburg.

Low Fowler's

HOB raised 15-30 degrees

Semi Fowler's

HOB 30-45 degrees

Standard Fowler's

HOB 45-60 degrees

High Fowler's

HOB 60-90 degrees

What is the purpose of using padding and pressure-relieving devices?

To prevent pressure injuries by redistributing pressure away from bony prominences.

What is the role of skin barriers in wound care?

To protect the skin from moisture and friction, reducing the risk of injury.

What is the impact of immobility on skin health?

Immobility increases the risk of pressure injuries due to sustained pressure on certain areas.

What is the importance of careful hand hygiene in wound care?

To prevent infection and promote healing of the wound.

What is the effect of chronic illness on skin integrity?

Chronic illness can impair circulation and healing, increasing the risk of skin breakdown.

What is the role of hydration in skin health?

Adequate hydration helps maintain skin elasticity and resilience against injury.

What is the primary goal in preventing pressure injuries?

To prevent skin breakdown and maintain skin integrity.

What daily assessments should be performed for at-risk patients?

Assess at-risk patients daily for signs of pressure injuries.

What routine care should be provided to prevent pressure injuries?

Cleanse the skin routinely and use moisturizers.

What is the significance of proper positioning in pressure injury prevention?

Proper positioning, turning, and transferring minimize skin injury from friction and shearing.

What role do nutritional supplements play in preventing pressure injuries?

Nutritional supplements may be needed to support skin health and healing.

How often should pressure-relieving devices be used?

Pressure-relieving devices should be used with Q2-3 hour turning.

What are silicone foam dressings used for?

Silicone foam dressings are effective in preventing pressure injuries, particularly on heels and sacrum.

What are the stages of pressure injuries according to the National Pressure Injury Advisory Panel?

Pressure injuries are staged 1-4, with additional classifications for Deep Tissue Pressure Injury (DTPI) and Unstageable.

What characterizes a Stage 1 pressure injury?

Intact skin with a localized area of non-blanchable erythema. Accompanying changes in temperature, consistency, sensation may precede visible changes

What characterizes a Stage 2 pressure injury?

Partial-thickness loss of skin with exposed dermis, may present as a serum-filled blister. The wound bed is viable, pink or red, moist. No visible subcutaneous fat or deeper structures. Granulation tissue, slough, and eschar are not present.

What characterizes a Stage 3 pressure injury?

Full-thickness skin loss with adipose (fat) visible, and granulation tissue, epibole (rolled edges), undermining or tunneling may occur. Slough/eschar may be present, but no exposure of deeper structures.

What characterizes a Stage 4 pressure injury?

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough or eschar may be present, and epibole, undermining, or tunneling often occur.

What is an Unstageable Pressure Injury?

Full-thickness tissue loss obscured by slough or eschar, preventing reliable staging.

What is a Deep Tissue Pressure Injury (DTPI)?

Intact or nonintact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister.

Why are wounds measured?

To check for tunneling or a wound that may be worse than it looks. Measure outside.

What is slough in the context of pressure injuries?

Dead tissue, usually cream or yellow, that may be present in a wound.

What is eschar?

Dry, black, hard necrotic tissue that may cover a wound.

What is necrotic tissue?

Non-viable tissue due to reduced blood supply.

What is maceration in relation to skin integrity?

Excessive moisture softens the skin, leading to breakdown and larger ulcers.

How should wounds be assessed?

Appearance: Size of wound, Depth of wound, presence of undermining, tunneling, or sinus tract

Drainage: Serous, Sanguineous, Serosanguineous, purulent

What is a skin tear?

Traumatic wound caused by mechanical forces (friction, shear, removal of adhesives) that involves separation of skin layers but does not extend through SQ tissue. Do not stage!

What should be done for skin tears?

Stop bleeding, use gentle cleansers, do not remove viable flap, no dry gauze, and apply non-adherent dressings.

What is the preferred dressing type for skin tears?

Silicone dressings are preferred; avoid dry gauze.

How are wounds treated?

Prevention. Pressure points and nutrition! Dressing to keep wound moist. Do not get surrounding tissue wet. "Pack" loosely. Wet to dry only if ordered. Wound VAC

What is the role of a Wound VAC in treatment?

A Wound VAC helps to maintain a moist wound environment and promote healing.

What is the significance of frequent position changes?

Small, frequent changes help to relieve pressure and prevent injuries.

What is the purpose of the Braden Scale?

It is a six-point risk assessment tool for evaluating pressure injury risk and skin breakdown. Includes sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

What does the Braden Scale assess regarding sensory perception?

It evaluates the ability to respond meaningfully to pressure-related discomfort.

1. Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli.

2. Very limited: Responds only to painful stimuli, communicate by moaning

3. Slightly limited: Responds to verbal commands but cannot always communicate discomfort

4. No impairment: Responds to verbal commands. Has no sensory deficit

What does the Braden Scale measure in terms of moisture?

It assesses the degree to which skin is exposed to moisture.

1. Constantly moist: Skin is moist almost constantly by perspiration, urine, etc. Damp every time

2. Moist: Skin is often but not always moist. Changed at least q_ shift.

3. Occasionally moist: Skin is occasionally moist, linen change x1.

4. Rarely moist: Skin is usually dry; linen requires changing only at routine intervals.

What are the activity levels assessed by the Braden Scale?

1. Bedfast: Confined to bed.

2. Chair fast: Ability to walk severely limited or nonexistent. Cannot bear own weight

3. Walks occasionally: Walks occasionally during day but for very short distances, Spends majority of each shift in bed or chair.

4. Walks frequently: Walks outside the room at least twice a day and inside room at least once every 2hours during waking hours.

How does the Braden Scale evaluate mobility?

Ability to change and control body position

1. Completely immobile: Does not make even slight changes in body or extremity position without assistance.

2. Very limited: Makes occasional slight changes inbody or extremity position but unable to make frequent or significant changes independently.

3. Slightly limited: Makes frequent though slight changes in body or extremity position independently.

4. No limitations:

What does the Braden Scale assess regarding nutrition?

1. Very poor - NPO, never eats a complete meal

2. Probably Inadequate - rarely eats a complete meal, generally only about ½ what is offered

3. Adequate - Eats over half of most meals or is on tube feedings or TPN

4. Excellent - Eats most of every meal

What are the categories for friction and shear in the Braden Scale?

1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair. Spasticity, contractures, leads to almost constant friction.

2. Potential problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position.

3. No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair

Define shear in the context of skin integrity.

The result of skin being pulled in one direction, however supporting structures such as muscle and bone do not move, or move in the opposite

Define friction in the context of skin integrity.

The result of the skin being moved one way while a surface is stationary, or moves in the opposite direction

What is the significance of documenting skin assessments?

Make sure you get this on admission or your agency takes responsibility. Document prevention as well as treatment as well as education. Document stage, length, width, depth, tunneling.

What are some local factors that impede wound healing?

Inadequate blood supply, increased skin tension, poor surgical apposition, wound dehiscence, poor venous drainage, presence of foreign body and foreign body reactions, continued presence of microorganisms, infection, excess local mobility.

What are some systemic factors that impede wound healing?

Advancing age and general immobility, obesity, smoking, malnutrition, deficiency of vitamins, systemic malignancy and terminal illness, shock, chemo/radiation, immunosuppressant drugs.

What are some hazards of bedrest beyond pressure ulcers?

Severe impact of m/s system and cardiac, pulmonary, and nutrition. Also big mental impact. Loss of muscle mass and bone density! High potential for neuro involvement. DVT.

What is the role of interprofessional collaboration in wound care?

It involves consulting with physical therapy, occupational therapy, and nursing to ensure comprehensive care.

What is the importance of range of motion (ROM) exercises?

Help prevent contractures and maintain joint function.

How are joints assessed in MS?

Inspection, palpation, ROM, and strength.

What is a contracture?

A fixed tightening of muscles, tendons, ligaments, or skin that prevents normal movement.

What is foot drop, and why is prevention important?

A condition that impairs the ability to lift the front part of the foot; prevention is crucial during extended bedrest.

What is the recommended frequency for passive ROM exercises?

Should be performed once per day. Extend, flxex, and rotate any way the join moves normally.

Describe the hip flexion exercise.

Support the leg under the knee and heel, bend the knee toward the chest while keeping the hip stable.

How is hip abduction performed?

Cradle the leg and move it away from the other leg while keeping the knee straight.

What is the procedure for ankle rotation?

Hold the ankle steady and turn the foot inward and outward while keeping the knee straight.

How should toe flexion and extension be performed?

Stabilize the foot and gently move each toe forward and backward.

What is the technique for heel-cord stretching?

Cup the heel and push the ball of the foot forward to stretch the muscles in the back of the leg.