Tissue Integrity - Day 2

Skin Assessment Study Guide

Introduction

  • Purpose: To assess and maintain skin integrity across various populations.

  • Learning Objectives:

    • Apply culturally competent care for skin integrity issues.

    • Perform skin assessments accurately.

    • Understand diagnostic and laboratory tests related to skin health.

    • Implement nursing interventions to promote skin integrity.

Subjective History

  • Family history of skin conditions (e.g., allergies, skin cancer)

  • History of skin allergies, reactions to food, medications, or chemicals

  • Previous skin conditions and treatments

  • Recent changes in moles or lesions

Physical Assessment

  • Assess skin, scalp, hair, and nails using inspection and palpation.

  • Ensure good lighting and comfortable room temperature.

  • Use gloves when palpating open or draining lesions.

  • Assess for cleanliness, odors, and moisture levels.

Best Practice Guidelines

  • Incorporate skin assessment into daily evaluations.

  • Perform an initial assessment within 8-12 hours of admission for at-risk clients.

  • Reassess based on patient condition and risk level.

  • Document findings thoroughly.

Inspection: Skin Color

  • Evaluate for cyanosis, ecchymosis, pallor, erythema, jaundice, petechiae.

  • Check areas such as palms, soles of feet, lips, tongue, and nail beds.

  • Differences in presentation for light vs. dark skin tones.

Inspection: Skin Lesions

  • Observe shape, size, location, color, consistency, elevation, drainage, pattern, and distribution.

  • Types of configurations: Linear, Annular, Zosteriform, Grouped, Discrete, Confluent.

Primary Skin Lesions

  • Flat lesions: Macule, Patch

  • Elevated solid lesions: Papule, Plaque, Wheal

  • Fluid-filled lesions: Vesicle, Pustule, Bulla

Secondary Skin Lesions

  • Changes in primary lesions due to infection, scratching, or treatment.

  • Examples include crusts, scales, scars, fissures, erosions, ulcers.

Specific Skin Conditions

  • Psoriasis: Autoimmune disorder with scaly, itchy patches; managed with corticosteroids, emollients, and UV therapy.

  • Contact Dermatitis: Inflammatory reaction from allergens or irritants; managed by avoiding triggers, using cool compresses, and applying steroids.

Skin Cancer Assessment (ABCDEs)

  • A: Asymmetry

  • B: Border irregularity

  • C: Color variation

  • D: Diameter > 6mm

  • E: Evolving in size, shape, or color

Vascular Lesions

  • Result from aging or blood vessel damage.

  • Include petechiae, purpura, ecchymosis.

Skin Palpation

  • Moisture: Smooth and dry is normal.

  • Temperature: Use dorsal hand; check for symmetry.

  • Turgor: Check for tenting to assess hydration.

Edema Assessment

  • Check for pitting by pressing over bony prominences.

  • Assess for shiny, tight skin.

Nail Assessment

  • Check for color, shape, thickness, capillary refill.

  • Abnormalities include clubbing, Beau's lines, spoon nails.

Hair and Scalp Assessment

  • Assess color, texture, thickness, lubrication.

  • Look for lice, alopecia, hirsutism, dandruff.

Diagnostic Tests

  • Biopsy, Patch testing, Diascopy, Culture and Sensitivity, Wood's light examination.

Wound Assessment

  • Evaluate appearance, size, approximation, drainage, and signs of infection.

  • Types of drainage: serous, sanguineous, serosanguineous, purulent.

Wound Care

  • Cleansing with saline for healthy wounds, antiseptics for contaminated wounds.

  • Dressings: occlusive, moisture-retentive, antimicrobial.

  • Use wet-to-dry dressings and negative pressure wound therapy for complex wounds.

Documentation

  • Document wound type, description, location, measurements, drainage, and surrounding tissue condition.