Comprehensive Skin Assessment: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit

– 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.

2 thoughts on “Comprehensive Skin Assessment: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit

  1. She conveys dedicated concern for all the neglected patients. When l was in heart surgery recovery, it took 6 days before anyone came to help me bathe in bed…supposed to have a bath or shower daily l found out!
    Thanks for your professionalism & apparent compassionate concern. 🌷💖

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