🧴 1. SKIN ASSESSMENT – DETAILED NOTES 📄 ⭐ Purpose of Skin Assessment * Identify early signs of breakdown * Detect circulation or oxygenation issues * Prevent pressure injuries * Monitor healing or worsening conditions 🧠 What You Assess (Head-to-Toe Skin Check) 🔹 1. Temperature * Warm = normal * Cool = ↓ circulation * Hot = infection/inflammation 🔹 2. Color * Pallor → anemia / ↓ oxygen * Cyanosis → poor oxygenation (BLUE = BAD) * Redness → inflammation / pressure 🔹 3. Turgor * Pinch skin (usually chest or forehead) * Normal = snaps back quickly * Tented = dehydration 🔹 4. Moisture * Dry → dehydration * Diaphoretic → fever, stress * Excess moisture → breakdown risk 🔹 5. Integrity * Intact vs open areas * Look for: * wounds * tears * ulcers 🔹 6. Capillary Refill * Press nail bed * Normal = < 2 seconds * Delayed = poor perfusion 🔹 7. Edema * Swelling = fluid buildup * Check severity (pitting scale) 🚨 PRIORITY AREAS TO CHECK * Bony prominences (sacrum, heels, elbows) * Skin folds (obese patients) * Under devices (oxygen tubing, stockings) * Areas with ↓ sensation ⚠️ HIGH-YIELD FINDINGS * Non-blanchable redness = Stage 1 pressure injury * Cool, pale skin = ↓ perfusion * Moist skin = ↑ breakdown risk 🩹 2. SKIN TRAUMA & PRESSURE ULCERS – DETAILED NOTES 📄 ⭐ What is Skin Trauma? Damage to the body’s protective barrier ⚠️ Causes of Poor Wound Healing * Malnutrition * Poor blood flow * Infection * Smoking * Medications (steroids) * Age 🧬 Wound Healing Phases 1. Inflammatory * Redness, swelling * Body sends immune cells 2. Proliferative * New tissue forms * Wound starts closing 3. Maturation * Remodeling * Scar forms 👉 Know the ORDER!! 🔥 Types of Wound Healing * Primary intention → clean, closed (sutures) * Secondary intention → open wound heals slowly * Tertiary intention → delayed closure 🚨 PRESSURE INJURIES ⭐ Causes: * Pressure * Friction * Shearing ⭐ Risk Factors: * Immobility * Incontinence * Poor nutrition * ↓ mental status 🔴 STAGES (VERY TESTED) Stage 1: * Non-blanchable redness * Skin intact Stage 2: * Partial thickness * Blister / shallow wound Stage 3: * Full thickness * Fat visible Stage 4: * Muscle or bone exposed Unstageable: * Covered with slough/eschar Deep Tissue Injury: * Purple/maroon skin 🚑 INTERVENTIONS (PRIORITY CARE) * Turn every 2 hours * Keep skin clean and dry * Use barrier creams * Promote nutrition (protein!!!) * Assess skin daily ❌ DO NOT: * Massage reddened areas ⚠️ COMPLICATIONS * Infection * Dehiscence (wound opens) * Evisceration (organs out = emergency) 🧴 3. SKIN CONDITIONS – DETAILED NOTES 📄 ⭐ COMMON CONDITIONS 🔹 Dryness / Pruritus * Dry, itchy skin * Causes: * dehydration * irritants * allergies Treatment: * Moisturizers * Antihistamines * Steroids 🔹 Urticaria (Hives) * Raised, itchy welts * Blanch with pressure Treatment: * Antihistamines * Steroids * Epinephrine (severe) 🔥 Psoriasis (VERY TESTED) * Chronic autoimmune disorder Signs: * Silvery scales * Red plaques * Common areas: * elbows * knees * scalp Treatment: * Steroids * UV therapy * Biologic drugs 🔥 Cellulitis (IMPORTANT) * Bacterial infection Signs: * Red * Warm * Swollen * Painful Treatment: * Antibiotics * Elevate extremity 🔥 Shingles (VERY TESTED) * Reactivation of chickenpox Signs: * Painful vesicles * Burning/tingling Key Point: 👉 Contagious to people who never had chickenpox 🔥 Skin Cancer Types: * Basal cell * Squamous * Melanoma (most dangerous) ⭐ ABCDE RULE: * A = asymmetry * B = border * C = color * D = diameter * E = evolving 🧠 Nursing Diagnoses: * Impaired skin integrity * Risk for infection * Pain * Disturbed body image 🛌 4

Purpose of Skin Assessment

To identify early signs of breakdown, detect circulation or oxygenation issues, prevent pressure injuries, and monitor healing or worsening conditions.

Temperature Assessment

Warm skin indicates normal conditions, cool skin indicates decreased circulation, and hot skin suggests infection or inflammation.

Pallor

Pallor refers to skin paleness, often indicative of anemia or decreased oxygen.

Cyanosis

Cyanosis is a condition characterized by blue skin, indicating poor oxygenation.

Skin Turgor

Normal turgor means the skin snaps back quickly after being pinched, while tented turgor indicates dehydration.

Moisture Assessment

Dry skin indicates dehydration, diaphoretic skin suggests fever or stress, and excessive moisture increases breakdown risk.

Integrity of Skin

Examine for intact skin versus open areas, looking for wounds, tears, or ulcers.

Capillary Refill

Pressing on the nail bed to test for normal refill time of less than 2 seconds; delayed refill indicates poor perfusion.

Edema

Swelling due to fluid buildup, evaluated using a pitting scale.

Non-blanchable redness

Indicates Stage 1 pressure injury, where the skin is intact.

Proliferative Phase of Wound Healing

New tissue forms, and the wound begins closing.

Tertiary intention in wound healing

Delayed closure of a wound, which has a more complex healing process.

Skin Cancer ABCDE Rule

Asymmetry, Border irregularity, Color variations, Diameter greater than 6mm, and Evolving appearance.

Risk Factors for Pressure Injuries

Include immobility, incontinence, poor nutrition, and decreased mental status.

Immobility Effects on the Musculoskeletal System

Leads to muscle atrophy and weakness.

Complications of Immobility

Includes DVT, pneumonia, pressure injuries, and constipation.

Interventions for Preventing Complications of Immobility

Turn patients every 2 hours, encourage ambulation, use incentive spirometers, and perform ROM exercises.

Common Nursing Diagnoses Related to Immobility

Impaired physical mobility, risk for skin breakdown, constipation, activity intolerance, and self-care deficit.

Pressure Injury Stages

Stage 1: Non-blanchable redness; Stage 2: Partial thickness; Stage 3: Full thickness; Stage 4: Exposed muscle/bone.

Signs of Cellulitis

Red, warm, swollen, and painful area indicating a bacterial infection.

Psoriasis

Chronic autoimmune disorder characterized by silvery scales and red plaques.

Severe Case Treatment for Urticaria

Include antihistamines, steroids, and epinephrine.