- A comprehensive skin assessment
is a very important piece to quality patient care.
An assessment should be done anytime a patient
is admitted to your facility,
transfers unit-to-unit,
is high-risk such as an ICU patient,
or is a terminal patient such as a hospice patient.
A skin assessment includes both palpation
and inspection.
And there’s certain points that you need
to keep in mind for a minimum assessment.
These include the skin’s temperature,
is it warm or cold?
Moisture – is it clammy, is it dry,
is it too moist?
Turgor of the skin, and color of the skin.
And finally, integrity of the skin:
are there any open areas or areas of redness
or concern that we need to report
and have further information or testing available
to determine the cause?
Once we’ve decided to go in
and begin our skin assessment,
we need to talk to the patient and tell them
what we’re going to do.
We want to make sure that there’s adequate privacy,
and that we expose no areas that we don’t need to
for patient modesty and comfort.
As we’re looking at the skin,
if we find any problems, we need to make sure
we’re explaining to the patient what they are,
where they are, and what we’re seeing.
We need to be sure we have adequate lighting
because shadowing can hide problem areas
that we might not be able to see.
Once we know exactly what we want to assess,
we’re going to go and start our actual skin assessment.
It’s a top to the bottom assessment,
starting with the head, working our way
down the body to the feet.
We need to keep in mind that sometimes we need
people to help us re-position the patient
if they’re unable to move by themselves,
or have serious contractures
that make turning very difficult.
While doing a head-to-toe assessment
sounds simplistic, certainly inspection/palpation
don’t sound too complicated,
this is one of the most important things
you’re going to do for your patient in terms
of planning care,
preventing pressure ulcers in your facility,
and allowing communication between you
and your patient in an intimate setting.
When we do a head-to-toe skin assessment,
we literally start at the head of the patient
and work our way down to the feet of the patient.
We’re going to start by looking
at her hair growth patterns.
We’re going to look for the coloration
of her face, her eyebrows, her eyes.
Because any skin or eye discolorations
that you notice could be the sign of
either skin cancers, vitamin deficiencies,
or other underlying pathologies such as
liver issues if her eyes are discolored.
We’re going to look behind her ears.
And around her ears.
And we’ll talk about this with tubing also.
We’re going to look at her lips,
her teeth, her mouth.
And it’s especially important to note
any sties around her eyes or any
abnormalities in her ear,
as often these are signs of skin cancer
and it’s the first time that they’re noticed.
Next, we’re going to look at the patient’s neck.
And the neck becomes particularly important
if the person has oxygen tubing or a mask.
And it’s especially important
if they have a cervical collar.
When we look around the cervical collar
it’s important to visualize the skin area
and look for areas of chafing or redness.
This is also true if the person has a neck brace
because the skin can become very irritated
around there if they’re moving their head very much.
Looking at the back of the neck is especially important
for pediatric patients or babies
because this is a frequent site of
pressure ulcer development that is often overlooked.
Now we’re going to talk about oxygen tubing.
And frequently it’s overlooked,
but it’s very important because the skin
is so thin on the face that the pressure
can cause wounds very quickly
that can become very deep.
We want to be very careful around her nares,
that we’re looking for areas of dryness
or irritation in this area.
We’re going to trace the tubing around her face,
look behind her ear to see if it’s pulled too tight.
We’re going to come down and make sure
it’s not tight around her chin that’s actually
causing pressure under here.
Finally, we’re going to trace it down
and make sure she’s not laying on any of the tubing
as this can cause a pressure ulcer in the spot
that she’s on top of the tubing.
When the patient has an oxygen mask on,
the areas of pressure may be a little bit different.
They can be on the cheekbones.
So it’s important to look anywhere that the mask
is tight on the face,
including over the bridge of the nose.
Trace the elastic around,
look for any areas of twisting,
and make sure it’s not so tight
that it’s pulling the patient’s skin.
How does that feel?
Next we’re going to look at the shoulders
and arms and hands of the patient.
We’re going to remove the gown only in the area
that we’re looking at so we preserve her modesty,
as well as keep her warm.
We’re going to work our way down,
paying particularly close attention to her elbow
which can become very dry,
or can become irritated from friction
of pushing herself up in bed.
In people that are sitting in the chair all day,
the underside of the arm can develop
a pressure ulcer from laying on the arm of the chair.
So it’s important to look for an unusual wound
in this area.
We’re going to continue on down the arm.
We’re going to look at the fingers.
Is there any clubbing, discoloration,
cyanosis in her fingertips?
Any arthritic deformities that can impact
her ability to do ADLs?
Then we’re going to assess her skin turgor.
We’re going to either do it on the back of her arm
or on the hand itself.
We’re going to do this by pinching her skin,
letting it go back down.
In our patient today, she’s well hydrated.
She has healthy skin.
In many of our older patients however, the skin,
the epidermis and dermis, is not attached
and you have sliding.
And this is going to predispose them to skin tears.
If you pinch the skin and it stays up,
it usually indicates dehydration.
Next we’re going to look at the chest
and abdomen of our patient.
Remember, when we do this, we’re only going to uncover
the area we’re examining to maintain her privacy.
We’re going to be sure to look for any raised
or discolored areas, areas of warmth or cold,
any areas that are hard or softer than surrounding tissue.
Scar tissue is also important to observe
because scar tissue never heals to the same
tensile strength as regular skin.
It’s especially important in the sacral area
where it can be the reason the person is at high risk
for developing a pressure ulcer.
In our bariatric patients, we’re going to look
between the skin folds.
Frequently, the skin folds are an area
that have moisture issues as well as pressure.
They’re often an area that can develop fungal infections.
In our female patients, we’re going to look
under the breast tissue as well,
for the same reasons.
As we start the back examination,
there are certain key points that you need
to keep in mind.
First, we need to see if there’s any tubing
that the patient has been laying on that
could be causing areas of pressure.
Another area of pressure is the sheets themselves.
If they've become wrinkled, they will cause damage
to the skin and areas of pressure.
Finally, we need to look for moisture.
Moisture can come from perspiration.
It can be from wound exudate.
Or it can be because our patient is incontinent.
If there’s any moisture, it will pool in the lowest spot
and get the bed wet.
This wetness will cause maceration of the skin and,
when we move our patient, the friction can cause damage.
At this point, if we need help because
our patient can’t move, we’re going to ask someone
to come in and help roll the patient over safely.
In this case, our patient was able to help turn herself.
We want to make sure that she’s comfortable and,
if necessary, give her a pillow under
her abdomen to lean against.
We’re now going to start with the back of the neck.
And we’re going to look for any twist ties
that might have caused damage from a trach tube
or in the case of a child or baby,
from being on their head for too long.
We’re going to look down and pay particular attention
to bony prominences.
We’re going to note any raised moles
that she might have that we might want to report.
We’re going to continue down her spine,
and we’re going to feel and touch for areas of firmness
or coldness or warmth.
This is especially important if we have someone
with darkly pigmented skin and we can’t see a
Stage One pressure ulcer very easily.
The sacral coccyx area is the number one site
of pressure ulcers.
Our weight is on this site when we’re sitting,
when we’re lying on our back.
And when we slip down in the chair,
the shear forces put extra emphasis on this area
that rapidly can lead to the development
of a pressure ulcer.
We also need to consider that moisture
and pressure damage might be present together.
It is important to be able to distinguish between the two.
In our older patients,
there can also be things like sebaceous glands
that have become blocked or hair follicles
that have caused a small abscess.
And we want to distinguish this from a pressure ulcer.
Remember, pressure has to be present to be a pressure ulcer.
If moisture and a wound are together,
we have to decide what we’re going to treat
and how we’re going to treat it.
Are we going to use barrier products,
are we using a dressing, are we trying to do both?
We also need to keep in mind that
if the person is incontinent,
the diaper may wick the moisture away
but the humidity at the skin remains really elevated,
leading to maceration.
And if stool incontinence is also present,
that stool remains on the skin.
And the urine and stool together increase the likelihood
of a person developing a pressure ulcer.
Next, we’re going to look at our patient’s legs and feet.
We’re going to look for any scars
that could indicate they had knee surgery
that could impact their mobility.
We also are going to feel both legs.
Make sure the temperature is the same in both.
Look for any areas of discoloration on the front
of the leg that could indicate some vascular issues.
Look for edema around the feet and ankle area.
We’re going to look at the toes, the ankles,
the entire foot to see if we have any arterial
or diabetic wounds that are developing.
Or areas of pressure that the person would need
to be fitted for proper shoes by a podiatrist.
We’re going to use a mirror to look at
the bottom of the heel...
Because the heel is the second most common site
of pressure ulcers.
In really large men, we’re going to look
at the bottom of the foot
because having it up against the footboard
causes an area of pressure that can lead to breakdown
in a very unusual area.
Anyone that we suspect that has vascular issues,
we want to use either a foot boot or we want
to elevate their leg in a pillow.
If we use a pillow, we want to be careful
we don’t hyperextend the knee, or that we cause
too much pressure to the tendon behind the ankle area.
It’s important to remember when we’re doing
the legs and feet, that if the person has foot boots on,
we want to make sure they’re properly positioned.
Otherwise they become twisted and
can cause us areas of more pressure.
In addition, we need to make sure all staff knows,
including our CNAs, that we have to take the socks off
and the boots, even TED hose, once a day
to actually examine the feet for any problems.
In addition, we need to make sure that there’s
no tubing, catheter tubing, SCD tubing,
anything under the patient’s legs that
could cause additional areas of pressure.
A comprehensive head-to-toe skin assessment
is a very important piece to providing quality patient care.
Much of the information about a head-to-toe
skin assessment can be found in the AHRQ Toolkit
for Preventing Pressure Ulcers in Hospitals.
It’s important to understand that a total head-to-toe
skin assessment is not done only one time.
This needs to be part of an ongoing plan of care.
And all staff needs to be involved in it.
Anytime a patient is turned, repositioned,
bathed, cleaned, the staff members need to be looking
at that area of skin.
Everyone needs to be aware of the patient’s risk,
and understand how their role translates
into the plan of care.
Documentation and communication are equally as important.
You may have done a wonderful skin assessment,
but if you don’t tell anyone what you’ve done,
they’re not going to know that it occurred.
This is especially important legally if anyone needs
to look at your medical records.
Communication between all levels of staff is critical.
One of the tools in this kit is a comprehensive diagram
of a patient that a CNA can use
to communicate with their RN.
They can show the nurse where the problem area is,
give them the time and date,
and then the nurse can go in and document
what they’re seeing and the extent of the problem.
The communication goes between all team members.
It goes shift to shift as well.
So please keep in mind that this is a critical piece
of you providing quality care.
And do the best job you possibly can with this assessment,
and with teaching your staff.