Head to Toe Skin Assessment

1. Head to Toe Skin Assessment Karen R. Brown BS, RN, CWS Wound/Ostomy Specialist

2. Objectives: • Describe essentials for maintenance of healthy skin • Discuss pressure ulcer risk assessment tools • Describe appropriate documentation of skin assessment SKIN ASSESSMENTS

3. Each square inch of human skin consists of twenty feet of blood vessels Humans shed about 600,000 particles of skin every hour - about 1.5 pounds a year. By 70 years of age, an average person will have lost 105 pounds of skin. A large amount of the dust in you home is actually dead skin A large amount of the dust in you home is actually dead skin Skin Facts

4. Skin Assessment Skin assessment important in the prevention of pressure ulcers, IAD, MADS,Intertrigo, etc. A complete skin assessment should include: Assessing for localized heat Edema Induration (hardness) Excessive moisture

5. Skin Care is important to protect the skin from breakdown: Not massaging skin Not turning the patient back onto a still reddened surface from previous pressure loading Not vigorously rubbing skin that is at risk for skin breakdown SKIN ASSESSMENT

6. What tools do we use? Eyes Hands Ears excellent history taking and data gathering Braden Scale Nutrition Assessment Tool

8. CONFINED TO BED/CHAIR • Preventative Actions • Look at skin at least once a day. • Bathe only when needed for comfort or cleanliness. • Prevent dry skin. Immobility/decreased mobility

9. For a person in a chair: 1. Change position every hour or as often as possible. 2. Use foam, gel, or air cushion to relieve pressure. • Reduce friction by: Lifting, rather than dragging, when repositioning. Using cornstarch on skin. • Involve physical therapy as needed. SKIN ASSESSMENT

10. Donuts are for eating Not sitting on NO DONUT SHAPED CUSHIONS

11. Change position at least every 2 hours. Use a special mattress that contains foam, air, gel, or water. Raise the head of bed as little and for as short as a time as possible. For a Bed Bound Patient

12. Loss of Bowel or Bladder Control Clean skin as soon as soiled with urine or stool. • Assess and treat urine leaks. • If moisture cannot be controlled: 1. Use absorbent pads and/or briefs with a quick-drying surface. 2. Protect skin with a cream or ointment.

13. Poor Nutrition Eat a balanced diet. • If a normal diet is not possible, talk to health care provider about food supplements

15. Lowered Mental Awareness Choose preventative actions for the person with lowered mental awareness. For example, if the person is chair-bound, refer to the specific preventative actions outlined in Risk Factor 1.

16. Support Surfaces

17. SKIN ASSESSMENT DOCUMENTATION

18. SKIN ASSESSMENT SKIN FOLDS DOCUMENT PRESENCE OF: MOISTURE RASH CANDIDA LESIONS 2007 Medline Industries, Inc.

19. xerosis Xerosis is a dermatosis exhibited as dry scaly skin with or without erythema (redness) and pruritus (itching) Caused by epidermal water loss Loss of natural moisturization factors LOCATION: Usually lower legs Sometimes trunk and hands

20. xerosis Clinically looks like Scaling, flaking skin Dull, white color and increased skin markings

21. DOCUMENTchanges in skin color excess skin moisture skin turgor changes in skin texture

22. SKIN ASSESSMENT DOCUMENT ULCER LOCATIONS OVER BONY PROMINENCES HISTORY OF PREVIOUS ULCERATIONS

23. SKIN ASSESSMENT PALPATE FOR WARMTH, TENDERNESS, BOGGINESS EDEMA DOCUMENT EVERY DETAIL

24. ASSESS MEDICAL DEVICES DOCUMENT TYPE OF DEVICE LOCATION TYPE OF SECUREMENT DEVICE

25. ASSESS MEDICAL DEVICES TUBE SITE EROSION HYPERGRANULATION TISSUE

26. BARIATRIC SKIN ASSESSMENT incontinence-related dermatitis secondary to inability to perform personal hygiene, pressure ulcers (including sites other than bony prominences), venous Insufficiency/ulceration, and/or lymphedema.

27. BARIATRIC SKIN ASSESSMENT The bariatric patient may not be able to clean the perineal area well enough or maybe not at all.

28. BARIATRIC SKIN ASSESSMENT Pressure ulcers not over bony prominences Increased propensity for venous ulcers with or without lymphedema Malnourishment

29. INCONTINENCE ASSOCIATED DERMATITIS (IAD) Incontinence-associated dermatitis is a common problem affecting as many as half of the patients with urinary or fecal incontinence who are managed with absorptive products.

31. SKIN CARE PROTOCOLS Clean after soiling and at routine intervals Avoid hot water Use mild cleansers non- irritating and non-drying agents Use moisturizers for dry skin Use barrier ointments/ sprays Powder bedpans

32. Use heel/elbow protectors or • socks • Use lift sheets or pads to move • patient • Limit head elevation to 30 • degrees and use knee gatch if • available • Use overhead trapeze (prevent • dragging patient up in bed) • Use footboards • Use light weight clothing and • covers (layering is best) • Minimize environmental factors • leading to drying such as low • humidity/exposure to cold SKIN CARE PROTOCOL

33. Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care. 2002;15:170-179. Ghadially R. Aging and the epidermal permeability barrier: implications for contact dermatitis. Am J Contact Dermat. 1998;9(3):162-169. Brown DS. Perineal dermatitis risk factors: clinical validation of a conceptual framework. Ostomy Wound Manag.1995;41(10):46-48, 50, 52-53. European Pressure Ulcer Advisory Panel and National Pressure Ulcer. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. References

34. Portable Instructional Education (PIE). Home Health Care 1st Edition. (CD) Wound Ostomy and Continence Nurses Society, WOCN National Office, Mt. Laurel, NJ; 2008. References