Skin Assessment - Class 2 Flashcards
thorough skin assessment is
paramount
what is key
prevention
early intervention is
critical
what should we identify
threats to skin integrity
visual inspection…
alone is not sufficient
parts of skin assesment
touch
observation (look with good lighting)
talk/document
smell
listen
2 overall assessments
subjective and objective
subjective assesment
subjective (RFs)
medical history
medications
nutrition
smoking, drugs, alc use
activity level
medical history –> subjective
diabetes
hypertension
renal dz
etc.
nutrition –> subjective
obesity/fragility
activity level –> subjective
exercise
mobility
ADL
objective skin assessment components
skin integrity
ethnicity
sensory status
moisture
atrophic changes
turgor/texture
nail composition and hair quality
edema, color and temp variations
observe skin folds
vascular status
lesions
callus
scar
skin integrity
is the skin in tact or does it present with injury
classify stage (if there is a pressure ulcer)
describe –> shape, size, depth, etc.
ethnicity
note skin tone and dermatological variants
sensory status
intact or altered
light touch –> location –> specific tests and soft tissue status
moisture
dry or moist to touch
normal
dry –> moisture
xerosis
flaking
scales
fissures
rash
wet –> moisture
sweat
weeping edema
incontinence
atrophic changes
shiny, hairless extremities
recommend vascular consult
turgor/texture
tent the skin on dorsum of hand to test
turgor
skin elasticity
normal v. delayed
texture
how does the skin feel?
normal, watery, softly pitting, brawny/fibrotic, hard/noncompressible
nail composition and hair quality
both are extensions of the skin
nails
color
shape
clubbing
thickness
hair
distribution
hair loss
what can color of the nails tell you
pale - anemia
half pink and half white - kidney dysfxn
yellow - lung dz or nail infection
half moons are red - lupus, heart dx, etc.
clubbing of the nail
nails are wider
chronic low O2
weak nails
vitamin B, calcium, iron deficient
thick nails
fungal infection
vertical ridges on nail
common as we age
decrease in vitamins A, B, D, keratin, etc.
horizontal ridges on nail
Beau’s lines
dysfxn of thyroid
vitamin deficient
injury
what is glaborous hair
non hairy regions
palms, soles
what is non glaborous
hairy regions
hirsutism hair
excessive body hair
alopecia
hair loss
thyroid
protein deficiency
hair shedding
thyroid dysfxn
hormone dysfxns
iron deficiencies
grey hair
stress or genetic
dandruff
sebhorric dermatitis
fungus
edema
note location
pitting or non-pitting
color
white, red, blue, yellow, black
pigmentation
pallor
cyanosis
jaundice
hyper/hypo
temp
normal, cool, warm or hot to touch
compare to the other side
observe skin folds
breast tissue, abdominal tissue, skin creases
what to look for in skin folds
skin breakdown
yeast/fungal infections
foreign objects
callus
indicates area(s) of high pressure or repetitive stress/trauma
scar –> normal trophic
normal
scar –> hypertrophic
high
w/in margins
scar –> keloid
high
beyond margins
scar –> immature
darker/red/raised/move as one
piece/immobile/sensitive/insensate
scar –> mature
lighter/flat. segmental movement/ mobile/ normal sensation
vascular status
look, listen and feel for color changes, doppler, palpate pulses, capillary refill, ABI and rubor of deficiency
lesions
rashes, scars, bruising, hemosiderin, nevi-birthmark or mole, etc.
document –> lesions
locations
describe presentation
formulate working clinical dx
denote anything unusual or suspicious
pulses
femoral
popliteal
dorsalis pedis
post tibial
pulse grades
0-4+
pulse grade –> 0
no pulse
pulse grade –> 1+
barley felt
pulse grade –> 2+
diminished
pulse grade –> 3+
normal
pulse grade –> 4+
bounding
assessment of pressure ulcers uses
braden scale
braden scale looks for
early identification of pts at risk for forming pressure sores
braden scale has
6 subscales
subscales of the braden scale
sensory perception
skin moisture
activity
mobility
friction and shear
nutritional status
the lower the braden scale
higher the risk of pressure sore development
high risk –> braden score
total score of 6-12
moderate risk –> braden score
total score 13-14
mild risk –> braden scale
15-18
no risk –> braden scale
19-23
wagner scale
for diabetic ulcers
asses ulcer depth and foot lesions in diabetic feet
how often to diabetic foot ulcers occur in those w/ diabetes
15%
what doesnt the wagner scale describe
infected or ischemic wounds
wagner scale –> grade 1
partial or full thickness ulcer
superficial
wagner scale –> grade 2
deep ulcer extended to lig, tendon, joint capsule, bone or deep fascia
w/o abscess or osteomyelitis
wagner scale –> grade 3
deep abscess
osteomyelitis or joint sepsis
wagner scale –> grade 4
partial foot gangrene
wagner scale –> grade 5
whole foot gangrene
university of texas wound class system
newer
more descriptive v. wagner
assesses wounds in the diabetic foot
texas –> grade 0
pre/post ulcerative state
texas –> grade 1
superficial wound
no tendon, capsule, bone involvement
texas –> grade 2
wound penetrates to tendon or capsule
texas –> grade 3
wound penetrates to bone or joint
what does the texas class system include
subsets to categorize infection and ischemia
