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Conducting a ComprehensiveSkin AssessmentPresented byDr. Karen Zulkowski, D.N.S., RNMontana State University

Welcome!Thank you for joining this webinar about how toconduct a comprehensive skin assessment.2

A Little About Myself An associate professor at MontanaState University Executive editor of the Journal of theWorld Council of EnterostomalTherapists (JWCET) and WCETInternational Ostomy Guidelines(2014) Member of the editorial board ofOstomy Wound Management andAdvances in Skin and Wound Care Legal consultant and former NPUAPboard member3

Today We Will Talk About Attributes and goals of comprehensive skinassessment How to conduct comprehensive skin assessment Treating comprehensive skin assessment as aseparate process Integrating comprehensive skin assessment intothe normal workflow Documenting and reporting results Improving comprehensive skin assessment Comprehensive skin assessment and careplanning4

Today We Will Talk AboutThese skin assessment topics were introduced inyour 1-day training. Today, we will revisit themin depth.Please make a note of your questions. YourQuality Improvement (QI) Specialists will followup with you after this webinar to address them.5

Attributes and Goals of ComprehensiveSkin Assessment Attributes of comprehensive skin assessment Goals of comprehensive skin assessment6

Attributes of ComprehensiveSkin Assessment Process of examining entireskin for abnormalities Requires looking at andtouching skin from headto toe7

Goals of Comprehensive Skin Assessment Identify any pressure ulcers. Find out if there are other lesions or skinrelated factors that predispose the patient todevelop pressure ulcers.– Factors include excessively dry skin and moistureassociated skin damage (MASD).8

Goals of Comprehensive Skin Assessment Identify other important skin conditions. Provide data needed to calculate pressureulcer incidence and prevalence. Stratify risk.– Patients with existing pressure ulcers are at riskfor more. Identify care planning needs.9

How To Conduct ComprehensiveSkin Assessment Standard protocol for comprehensive skinassessment 5 parameters of comprehensive skinassessment Skin assessment of bariatric patients10

Standard Protocol for ComprehensiveSkin Assessment Explain to the patient and family that you willbe checking the patient’s entire skin.– Explain what you are looking for with each site. Conduct the assessment in a private space. Make sure the patient is comfortable. Wash and sanitize your hands before and afterthe assessment.11

Standard Protocol for ComprehensiveSkin Assessment Wear gloves, and change them as needed. Minimize exposure of body parts.– Provide privacy with a sheet or cover. Ask for help to turn the patient as needed.Know your facility’s policies and procedures.12

Standard Protocol for ComprehensiveSkin AssessmentPay special attention to— Skin beneath and around any devices orcompression stockings Bony prominences (heels, sacrum, occiput) Skin to skin areas, such as the penis, back ofknees, inner thighs, and buttocks All areas where the patient—– Lacks sensation to feel pain– Had a breakdown previously Also pay special attention if the patient is gettingepidural/spinal pain medicines.13

5 Parameters of ComprehensiveSkin Assessment1.2.3.4.5.TemperatureTurgor (firmness)ColorMoisture levelSkin integrity– Skin intact– Open areas, rashes, etc.14

Parameter 1: Skin Temperature Palpate with your hand to assess skintemperature. Skin warmth or coolness can indicate skindamage, including—– Stage I pressure ulcer– Suspected deep tissue injury– Preulceration in the diabetic foot– Inflammation or infection15

Parameter 2: Skin Turgor (Firmness) Skin normally returns to its original statequickly when stretched. Can you “tent” the skin? Skin may be slow to return to its originalshape in older or dehydrated patients.16

Parameter 3: Skin Color Compare adjacent areas of skin for color. Redness can indicate many skin problems—– Pressure ulcer– Rash– Infection, cellulitis Deficiencies can also affect skin:– Vitamin C deficiency causes purplish blotches onlightly traumatized areas.– Zinc deficiency causes redness of the nasolabialfold and eyebrows.17

Parameter 3: Skin Color Blanchable versusnonblanchable erythema Purple or bruised lookingskin Paper-thin skin Dark or reddened areasDarkly pigmented skin does not blanch.18

Parameter 3: Skin ColorRedness Reddened skin on the sacral area can be from avariety of etiologies. Make sure to get the etiology right so you can treatthe cause appropriately.Moistureassociated skindamageStage I pressure ulcer19

Parameter 4: Skin MoistureMoisture-associated skin damage: Skin can be dry (verosis) or damagedfrom too much wetness (maceration). Etiology can be—––––Incontinence, urine, stool, or bothWound exudatePerspiration, including patients with a feverBetween skin folds (especially in bariatricpatients)– Ostomy or fistula that leaks Make sure to get the etiology right soyou can treat the cause appropriately.20

Parameter 5: Skin Integrity Skin should be intact. If skin is not intact, identify the etiology of theskin problem. Etiology could be—–––––PressurePeripheral vascular (venous or arterial)Neuropathic/diabeticSkin tears (especially forearm of older adults)Trauma Make sure to get the etiology right so you cantreat the cause appropriately.21

Skin Assessment of Bariatric Patients Inner aspect of thighs and skin foldsRashMacerationInfection (bacteria or candidiasis)Breakdown22

Skin Assessment of Bariatric Patients Perineum– Dermatitis– Candidiasis Extremities– Vascular changes– Edema– Lymphedema23

Treating Comprehensive Skin AssessmentAs Separate ProcessComprehensive skin assessment— Requires a specific focus by staff. Must be standardized and ongoing.24

Treating Comprehensive Skin AssessmentAs Separate ProcessFrequency of comprehensive skin assessment— Depends on the needs of the unit May be as often as every shift Is most often daily and when the patient is—– Newly admitted– Moved to a different level of care– Transferred– Discharged25

Integrating Skin AssessmentInto Normal WorkflowEach time you— Apply oxygen, check the patient’s ears forpressure areas from tubing Check bowel sounds, look at skin folds Reposition the patient in bed, check the backof the patient’s head26

Integrating Skin AssessmentInto Normal WorkflowEach time you— Auscultate lung sounds or turn the patient,check the patient’s shoulders, back, andsacral/coccyx region Check a male patient’s catheter, check hispenis Position pillows under the patient’s calves,check the heels and feet– Use a hand-held mirror to adequately visualizethe area.27

Integrating Skin AssessmentInto Normal WorkflowEach time you— Check IV sites, look at the patient’sarms and elbows Lift the patient or provide care,check exposed skin, especially onbony prominences Remove equipment, checkadjacent skin– This includes TENS units, restraints,splints, oxygen tubing, andendotracheal tubes.28

Documenting and Reporting Results Documenting results Reporting results29

Documenting Results Document the results of comprehensive skinassessment in each patient’s medical record—even if there are no problems. Have a standardized place to record results inthe medical record. Options include—– Checklist or standardized computer screens withkey descriptors of the 5 Parameters– Diagram of a body outline where staff can noteany skin changes they observeMake sure all staff know how and where to document results.30

Pressure Ulcer Identification Pocket PadTool 3CPage 13231

Documenting ResultsThink about keeping a unit wide log.For each patient, record— Whether he/she has pressure ulcers How many pressure ulcers he/she has Highest stage of his/her deepest ulcer Treatment for any existing wounds32

Reporting Results Include results in all shift reports. Make sure results are easy to access. If there are problems, report results to teammembers and to the patient’s health careprovider.33

Reporting Results If you keep a unit wide log*, review the log ona regular basis to:– Make sure comprehensive skin assessment hasbeen done for each patient.– Make sure the assessment and treatment ordersare current.– Assess your incidence and prevalence rates.All staff should know what your unit incidence and prevalencerates are and why they matter.*Tool 5APage 14734

Improving Comprehensive Skin AssessmentTrain all staff on: Who will conduct comprehensive skinassessment:– Nurse aide examines the skin each time he/she cleansor repositions the patient.– Nurse makes sure the assessment is comprehensiveand documented. Why to conduct it.When to conduct it.How to conduct it.What to look for.35

Improving Comprehensive Skin AssessmentEncourage staff to: Ask a colleague or expert to confirm their skinassessments.– This hones skills and prevents errors. Ask questions as needed. Report any possible skin abnormalities theycome across during routine care.36

Skin Assessment and Braden ScaleYou need to look at boththe skin assessment andthe risk assessment fromthe Braden Scale to planyour care appropriately.37

Skin Assessment and Care PlanningHead-to-toeskin assessmentINSPECT AND PALPATEAssessingskinPatient is admitted or readmittedDO BOTHComplete head-to-toe SKIN and PU RISKassessment on admissionDo both more frequently if significantchange occurs or per facility protocolDocument all skin issues, including:Skin colorSkin temperatureSkin turgorSkin moisture statusSkin integrityDOCUMENT-Moisture- Moles-Bruises-Rashes-Incisions-Scars-BurnsAny abnormalitiesRemember to pay specialattention to the feet and heelsReport anyabnormal findingsto HCP and notify& educate patientand family onfindingsZulkowski & Ayello, 201038

Skin Assessment and Care PlanningTool 3APage 12839

Today We Talked About Attributes and goals of comprehensive skinassessment How to conduct comprehensive skin assessment Treating comprehensive skin assessment as aseparate process Integrating skin assessment into the normalworkflow Documenting and reporting results Improving comprehensive skin assessment Skin assessment and care planning40

Any Questions?Thank you for being such great listeners.Do you have any questions about how toconduct a comprehensive skin assessment?Please refer any questions you have to your QISpecialists.41

Resources Berlowitz D, VanDeusen C, Parker V, et al. Preventing pressure ulcers in hospitals: atoolkit for improving quality of care. (Prepared by Boston University School ofPublic Health under Contract No. HHSA 290200600012 TO #5 and Grant No. RRP09-112.) Rockville, MD: Agency for Healthcare Research and Quality; April 2011.AHRQ Publication No. 11-0053-EF.– Tool 3A: Pressure Ulcer Prevention Pathway for Acute Care– Tool 3C: Pressure Ulcer Identification Notepad– Tool 5A: Unit Log Baranoski S, Ayello EA. Wound care essentials: practice principles. 3rd ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2011.Black J, Gray M, Bliss DZ, et al. MASD Part 2: Incontinence-associated dermatitisand intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs2011;38(4):359-70.Colwell JC, Ratliff CR, Goldberg M, et al. MASD Part 3: Peristomal moistureassociated dermatitis and periwound moisture-associated dermatitis: a consensus.J Wound Ostomy Continence Nurs 2011 38(5):541-53.Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage:overview and pathophysiology. J Wound Ostomy Continence Nurs 2011;38(3):23341.42