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.