The subject of my previous blog on skin assessment was interview; here in part 2, we will look at the elements of observation. Interviewing clients and significant others can provide the clinician with valuable information related to the client’s knowledge of their situation and a historic review of skin issues or potential events. However, observation is also necessary in a comprehensive skin assessment.
As persons age, there are many changes affecting the skin that we will address, so observation and clinical examination of the overall vascularity, neurological status, locomotor function, skin and nails, as well as footwear, are critical. Laboratory or hospital tests include those analyzing urine, blood, bone, heart, and nerve status. As clients are admitted to long-term care facilities, a review of past and current laboratory results can provide insight into treatment of skin issues. Please do not dismiss these reports as old or irrelevant.
The process of wound healing is somewhat altered in older adults relative to the progressive loss of skin function, decreased homeostatic abilities, and an increase in environmental vulnerability. A few aging-related changes considered “normal” include a 50% reduction in the rate of keratinocyte migration, which is a key process in wound repair. Altered dermal structures result in diminished pain and pressure reception. Elastin displays a disordered morphology that decreases elasticity. Older adults are predisposed to separation of the dermal-epidermal junction from laterally applied tension secondary to decreased surface contact between these layers. There is a decrease in number and function of antigen-presenting cells that impairs immune function when wound healing is necessary. Impaired homeostasis, inflammation, proliferation, and resolution results in slower healing.
These elements give us a framework for the plethora of information a clinician takes in the second they look at the client. Yes, the minute you see your client an assessment starts. What is their posture, the expression on their face, their color, any odors, any motor or spatial issue recognized? Observe their movement; coming into your line of vision, are they walking, how do they rise from sitting to standing, transfer from one surface to another? Do they remove their own shoes and socks, and if so, how? At what level is their personal hygiene?
Assessing your client’s skin for current breakdown or signs that breakdown is imminent in long-term care must happen immediately on the client’s arrival at your building. Pressure injuries can be lurking just under the surface, and you will be held accountable if an assessment is not completed and documented. Even worse, your client will suffer! At this point, ask yourself what tool do we have available to measure an individual’s risk for skin breakdown?
A leap was made there! Yup, your big concern in skin assessment observation is the client’s risk for skin breakdown. Whatever tool you have or are choosing, consider its ease of use and functionality in goal setting for outcome resolution. Use caution in setting up and applying a numbered scale that does not translate into direct care or planning for outcomes. Make sure it’s not just another piece of paper compliance! Norton and Braden scales have been proven valid and demonstrate moderate to good specificity. Use the picture painted by these tools to visualize your client and the needed path to recovery or maintaining healthy skin.
Tools provide a document of your observations, with skin issues specifically scored in relation to physical condition, mental status, activity, mobility, incontinence, and nutrition. Additional tools for documentation of anecdotal notes is required; if something does not fall into the categories listed that relate to a scoring system, it needs to be documented somewhere else.
Your visual examination may require some other kinds of tools: a flashlight, magnifying glass, tape measure and/or a mirror, to name a few. Employ all your senses—well, maybe not your sense of taste for this one. Smell the person or wound, feel the temperature of the skin, feel for pulses and underlying abnormalities of structures, listen to the client’s body, and look at everything! Know from your study of anatomy and physiology how the parts and pieces of the body develop to be a human, how they work. Incorporate the information about aging-related changes and the client’s health history into what you are seeing to understand the potential risk for skin breakdown. Now chart the course for care based on the gained knowledge from your assessment.
About the Author
Susan M Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary, is Wound Care Certified through the National Association of Wound Care since 2004. Sue consults in long-term care (LTC) and alternate-care settings on wounds, skin care, and various other issues. She has been employed in the LTC setting since 1969 and spent 25 years in an LTC rehabilitation facility where the focus was wound healing therapies.
NADONA/LTC has been the leading advocate and educational organization for directors of nursing, assistant directors of nursing, and nurses in LTC since 1986. With 40 state chapters, it continues to be the largest organization representing nurses working in both post-acute and LTC settings. NADONA/LTC offers a wide array of services to its members, including educational materials; conferences; executive fellows program, webinars, and scholarships; Nurse Leader, Licensed Practical Nurse, and Assisted Living certification programs; a mentoring program; and a quarterly journal, The Director. Through its publications and programs, NADONA/LTC reaches approximately 20,000 nurses who are employed in LTC. For more information regarding NADONA/LTC, please contact their offices at 800-222-0539 or visit their website at www.nadona.org.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.