🧴 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
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