🧴 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

🧴 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. IMMOBILITY – DETAILED NOTES

📄

⭐ What is Immobility?

Inability to move or limited movement

🚨 AFFECTS EVERY BODY SYSTEM

🔹 Musculoskeletal

• Muscle atrophy

• Weakness

🔹 Respiratory

• Atelectasis

• Pneumonia

🔹 Cardiovascular

• DVT

• ↓ circulation

🔹 Gastrointestinal

• Constipation

🔹 Integumentary

• Pressure ulcers

🔹 Renal

• Kidney stones

• Urinary stasis

🔹 Neurological

• Confusion

• Depression

🧠 Psychological Effects:

• Anxiety

• Depression

• Sleep changes

🔥 PRIORITY COMPLICATIONS:

• DVT

• Pneumonia

• Pressure injuries

• Constipation

⭐ INTERVENTIONS

Prevent complications:

• Turn q2h

• Encourage ambulation ASAP

• Use incentive spirometer

• Perform ROM exercises

• Increase fluids + fiber

🧠 COMMON NURSING DIAGNOSES:

• Impaired physical mobility

• Risk for skin breakdown

• Constipation

• Activity intolerance

• Self-care deficit

🔥 FINAL HIGH-YIELD SUMMARY

If you remember NOTHING else:

👉 Non-blanchable redness = Stage 1
👉 Turn patients q2h
👉 Immobility affects EVERYTHING
👉 Older adults = high risk
👉 Do NOT massage red