Comprehensive Notes on Skin Assessment and Integrity

Skin Assessment - Upper and Lower Extremities

• Systematic examination, comparing both sides for symmetry.
• Assess lesion characteristics if applicable.
• Palpate skin for temperature, texture, and moisture.

Braden Scale for Pressure Ulcer Risk

• Assessment tool to predict pressure ulcer risk.
• Factors evaluated:
  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and shear

Health History Review

• Changes in skin color, presence of rashes, dryness, or oiliness.
• Moles or changes in existing moles (potential sign of skin cancer).
• Sun exposure and protective measures.
• Swelling or edema.

Importance of Baseline Data

• Crucial for assessing changes indicating health issues.
• Example:
  • New or changing moles may indicate skin cancer.
  • New leg swelling may indicate peripheral edema (associated with heart disease or kidney problems).

Skin as a Window to Health

• The skin is the largest organ and reflects overall health.
• Assessment must be thorough as a key nursing skill.

Clinical Significance of Color Changes

• Cyanosis: Bluish color.
  • Indicates increased deoxygenated hemoglobin due to hypoxia.
  • Associated with heart or lung disease, or cold exposure.
  • Observe nail beds, lips, mouth, and skin.
• Pallor: Decrease in skin color.
  • Signifies reduced oxyhemoglobin, possibly due to anemia.
  • Observed on the face, conjunctiva, nail beds, and palms.
• Pallor from Shock: Reduced visibility of oxyhemoglobin due to decreased blood flow.
  • Affects skin color, nail beds, conjunctiva, and lips.
• Jaundice: Yellow-orange tint.
  • Indicates increased bilirubin, suggesting liver disease or red blood cell destruction.
  • Check sclera, mucous membranes, and skin.
• Erythema: Reddening of the skin.
  • Increased visibility of oxyhemoglobin due to vasodilation or increased blood flow.
  • Caused by fever or alcohol intake.
  • Seen on face, areas of trauma, sacrum, shoulders, or pressure injury prone areas.

Moisture

• Indicates body fluid imbalances, environmental changes, or body temperature regulation.
• Skin is normally smooth and dry, except in skin folds.
• Observe perspiration, oiliness, and any abnormalities (dryness, flaking).

Temperature

• Reflects blood circulation through the dermis.
• Increased temperature: possible erythema.
• Decreased temperature: reduced blood flow.
• Assess with the back of the hand, comparing symmetrical body parts.

Texture

• Palpate skin lightly to determine if skin is smooth, rough, thin, thick, tight, supple, indurated, or soft.
• Expect variations (thicker skin on palms and soles).

Skin Turgor

• Indicates skin elasticity.
• Assess by pinching skin on the forearm or sternum; observe how quickly it returns.
• Poor skin turgor indicates dehydration and predisposition to skin breakdown.

Vascularity

• Blood vessel visibility and color changes provide information about local skin pressure, systemic issues, or capillary fragility.
• Assess color changes and pressure areas for potential bedsores or pressure sores.
• Aging capillaries become more fragile.

Petechiae

• Non-blanching pinpoint red or purple spots (petechiae).
• May indicate clotting disorder, drug reaction, or liver disease.

Lesions

• Abnormalities on the skin.
• Benign or indicate a disease process.
• Primary lesions: initial reaction (e.g., insect bite).
• Secondary lesions: arise from further changes or trauma (e.g., infection, chronic pressure).
• Assess:
  • Color
  • Location
  • Texture
  • Size
  • Shape
  • Type
• Grouping (solitary, clustered, linear)
• Distribution (localized vs. generalized)
• Exudate (discharge, color, odor, consistency)
• Measure and document the size of lesions.

ABCDE System for Skin Cancer Detection

• System to detect possible skin cancer.
• Also consider primary lesions, secondary lesions, and vascular lesions.

Primary vs Secondary Lesions

• Primary lesions: Initial changes in healthy skin.
• Secondary lesions: Caused by progression or manipulation (scratching, infection).

Nail Assessment

• Angle between nail base and skin: should be 160 degrees (normal).
• Curvature: nail plate should have a slight curve when viewed from the side.

Clubbing

• Abnormal finding.
• Angle greater than 160 degrees.
• Indicates chronic low oxygen levels in the blood (heart or lung condition, emphysema, chronic bronchitis).
• Severe cases: angle may exceed 180 degrees.
• Nail bed appears to bulge outwards.

Capillary Refill Test

• Purpose: Assess peripheral circulation.
• Procedure: Press nail bed until blanching occurs, then release.
• Normal finding: Color returns in less than three seconds.
• More than three seconds: Poor blood circulation or cardiovascular issues.
• Correlate with other signs and symptoms to assess cardiovascular issues.

Hair Assessment

• Distribution of hair.
• Hair loss (Alopecia): Possible endocrine disorders (thyroid), nutritional deficiencies, or stress.
• Abnormal findings
• Uneven hair loss or growth can mean underlying condition

Hirsutism

• Excessive body hair in women in areas where men typically grow hair (face, chest).
• Caused by hormonal imbalances, menopause, or endocrine disorders.
• Also Assess pubic hair.

Peripheral Pulses

• Grading scale: 0 to 4+ (2+ is normal - strong and regular).
• Assess peripheral pulses during skin assessment.

Edema

• Medical term for swelling caused by excessive fluid trapped in body tissues.
• Commonly seen in lower legs, ankles, and feet.
• Possible causes or conditions: Heart condition, kidney disease, liver disease, or prolonged standing/sitting.
• Causes
  • Increased capillary pressure(Heart failure)
  • Decreased plasma proteins (Liver disease, malnutrition)
  • Obstruction of lymphatic drainage(Lymphedema, l y m p h e d e m a)
  • Increased capillary permeability (Inflammation or injury)

Pitting Edema Test

• Press thumb firmly but gently into the swollen area for at least five seconds.
• Release; observe if the skin indents (pit present).
• Grading scale: 1+ to 4+ (4+ is deep indentation lasting a long time).
• Non-pitting edema: No indentation after pressing; associated with conditions like lymphedema or myxedema (m y x e d e m a).

Associated Symptoms of Edema

• Pain (Possible deep vein thrombosis).
• Shortness of breath (Especially when lying down).

Concern about Edema

• Rapid onset (Sign of a serious condition).
• Severe swelling with pain, redness, or warmth (Immediate medical intervention needed).

Skin Integrity - Pressure Injury(Pressure Ulcer)

• Injury due to prolonged pressure on the skin.
• Reduces or cuts off blood flow to the skin and underlying tissues.
• Leads to tissue damage and possibly death.
• Occurs mostly on bony prominences(Heel, ankles, hips, tailbone).
• Constant pressure on the area reduces skin blood flow to the tissues.
• Risk factors
  *Immobility
  *Shear
  *Friction between the skin against bedding or clothing - which can damage the outer layer of the skin

Risk Factors for Pressure Injuries

• Immobility.
• Poor nutrition and hydration(Weakens skin and makes it more prone to injury. Thinner skin will be more susceptible to preasure injuries).
• Excessive Moisture (sweating, incontinence or wound drainage - weakens the skin)
• Decreased sensation:
  • Spinal cord injury, diabetes (neuropathy).
• Age (thin skin, less elasticity, chronic health risks).
• Blood flow(Affects blood flow, it will increase risk of injuries).

Key Terms

• Tissue ischemia
• Hyperemia
• Blanchable hyperemia
• Nonblanchable erythema
• Blanching

Classification of Pressure Injuries

• Stage 1: Non blanchable erythema of intact skin (warmer or cooler, swollen, texture differences, discomfort).
• Stage 2: Partial thickness skin loss with exposed dermis (reddish/pink wound bed, may resemble a blister).
• Stage 3: Full thickness skin loss, exposing subcutaneous fat (rolled edges, slough or eschar may be present, no muscle/bone exposure, possible undermining and tunneling).
• Stage 4:
  • Full thickness skin and tissue loss (muscle, tendons, ligaments, cartilage, or bone exposure, tunneling and undermining are common).
• Unstageable pressure injury: Depth of injury cannot be determined due to slough or eschar.

Wound Dressing

• Absorbent
• Non-adherent material (does not stick to wound bed)
• Damp to damp (mechanical debridement)
• Self-adhesive transparent film (temporary protective layer; see wound)
• Hydrocolloid (occlusive dressing for moist environment-prevent moisture loss).
• Alginates (highly absorbent, conform to the shape; for assisting in debridement).
• Collagen (promoting healing and hemostasis)
• Vacuum Assisted Closure System (Wound Vac- speeding up tissue generation).

Stages of Wound Healing

• Inflammatory, Proliferative, Maturation
  • Inflammation= Blood vessel constricting to control the bleeding(Oxygen and nutrients are being supplied.).
  • Proliferative=New epithelial cells form over the surface.
  • Maturation=The wound is gaining a more normal appearance/collagen scar strengthens.

Healing Processes

• primary/secondary/ and tertiary

Wound Drainage

• Describing the drainage you are using and how frequent you are doing dressing changes.

Dehiscence and Evisceration

• Dehiscence= increased serosanguineous drainage/ popping or I think my wound has given way - visible separation of wound edges.
• Evisceration= when the organs protruding through the wound opening (healthcare delivery system recorded lecture in your discussion tab this Thursday).