By Karen Zulkowski DNS, RN, CWS
Looking at a person's skin from head to toe is an important nursing function. Certainly nurses document this on the patient's admission, but not so much thereafter. Often the CNA is the first person to notice a problem. Yet there may not be good communication between disciplines or training of the CNA to understand the significance of what they are observing.
First, staff need to know how often they should perform a skin assessment, for example, q shift, q day, each home visit. Does the assessment need to be head to toe or should it be more frequent only in areas of pressure or under medical devices? How are issues communicated between disciplines? In acute care persons, areas at high risk for pressure ulcer development should be assessed at least every shift. In ICU patients, their medical instability also predisposes them to skin problems and pressure ulcer development. This is also true in palliative care patients. Skin failure at life's end may be sudden and a person with no wound in the morning has a stage II or stage IV wound in the afternoon.
To do a good skin assessment you have to touch the person. Some things such as color may be observed but others such as turgor and moisture involves contact. Skin color should be observed in total. Color may be normal for ethnic group, ashen, pale, cyanotic, flushed, jaundiced or mottled. Skin turgor assessment is easy to do by pulling up on the skin at the back of the hand, and may indicate decreased elasticity and risk for skin tears or dehydration. Adjectives to describe turgor include: good elasticity (normal), poor/decreased elasticity and tenting of skin.
Skin must be felt to determine temperature: cold, cool, warm (normal), or hot. Changes in one area may indicate skin damage or a worsening wound. In lower extremities this may be due to decreased circulation. If skin is cool, cold or hot overall, it could be a medical emergency or in person's that can't communicate the room temperature may need adjustment. Skin should also be assessed for moisture overall and then condition overall. For moisture, determine if skin is normal, moist, diaphoretic or clammy as these may indicate worsening medical conditions. Then overall is the skin dry, extremely dry (flaking) normal, oily or friable.
If the person has a wound it is important to assess the surrounding skin. This helps you decide if the wound is improving, stalled or deteriorating. Determine if the skin shows blanching, blistering, dryness, ecchymosis or erythema surrounding it. Also determine if the surrounding skin is inflamed, calloused, edematous, excoriated, friable or hemorrhagic. Feel the skin for signs of induration, hardness, bogginess or temperature changes. Other assessment items may include maceration, increased pain, or presence of scar tissue.
Knowing the characteristics of your patient's skin helps with risk assessment and care planning. The patient risk is more than the sum of the Braden Scale and all team members have to understand their role in providing care.
About The Author
Karen Zulkowski DNS, RN, CWS is an Associate Professor with Montana State University-Bozeman, teaches an online wound course for Excelsior College, and is a consultant for Mountain Pacific Quality Improvement Organization. She has served as a Research Consultant with Billings Clinic Center on Aging, and was the Associate Director for Yale University’s Program for the Advancement of Chronic Wound Care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
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.