Skin assessment and girth

Question 1

What does a skin assessment tell us

Answer 1

• underlying pathologies
• environmental influences
• inappropriate management

Question 2

Skin assessment should look at

Answer 2

• skin color
• skin temperature
• turgor
• moisture
• skin integrity
• edema

Question 3

What to look at in rearguards to skin color

Answer 3

• difference in color (one side to another)
• check for redness, darker areas, paleness, flushing, cynaosis

Question 4

Blanchable erythema

Answer 4

• visible skin redness that becomes white when pressure is applied and returns when pressure is removed
• represents an intact capillary bed

Question 5

nonblanchable erythema

Answer 5

• visible skin redness that resists with the application of pressure
• do not blanch/turn white
• indicates structural damage to the capillary bed/microcirculation
• can be an independent predictor of pressure ulcer development

Question 6

What to look at with skin temp

Answer 6

• use back of hand
• compare different areas

Question 7

turgor

Answer 7

• reflection of skin elasticity
• changes can be found in those who are older, dehydrated, edematous, who have CT disorders etc.
• to assess pinch the skin on the back of the hand
• let it go and see if it returns to place
• if it does not return = tenting
• indicates loss of elasticity often related to fluid or moisture loss

Question 8

Moisture of skin

Answer 8

• check for evidence of moisture, incontinence, excessive perspiration, wound drainage, lymphorrhea
• note any odor

Question 9

What is moisture associated skin damage (MASD)

Answer 9

• skin damage caused by sustained moisture
• incontinence, wound exudate, perspiration

Question 10

Maceration

Answer 10

• softened by liquid
• when you take off a bandage

Question 11

Skin integrity

Answer 11

• is the skin intact without cracks or openings
• is there bruising, evidence of itching, excoriation
• any evidence or rashes, raised lesions, skin injury, lacerations, surgical incisions
• can assess for change in tissue consistency: soft, boggy, hard

Question 12

Edema - what to assess?

Answer 12

• determine if edema is unilateral or bilateral
• grade and or objectively measure the edema
• to grade edema - firmly apply pressure for 5 seconds, then release the pressure

Question 13

Measure of edem

Answer 13

• girth measurements: tension should maintain contact with skin without indenting skin (figure 8/bony landmarks)
• volumetric: measures displacement of water
• edema scale: less objective but standardized

Question 14

Documentation

Answer 14

• document abnormalities
• be clear on location
• make referrals or educate as needed
• follow up as needed
• often, for wounds, special assessment forms my be available and will provide a means for a more comprehensive assessment