SKIN ASSESSMENT

Why is it important to consider the effects of laboratory and diagnostic testing on skin integrity?

• Venipuncture is invasive; complications include bleeding from the puncture site, hematoma, cellulitis, phlebitis, and infection or sepsis.
• Diagnostic procedures often involve the use of imaging tables and positioning equipment that are sometimes used over long periods of time and that may cause interface pressure damage to the skin.
• Laboratory procedures (specimen procurement) and diagnostic procedures (patient positioning) can cause skin complications—laboratory and diagnostic procedures are also used to predict risk for, identify, or monitor therapy administered for skin complications.

PATIENT CARE APPLICATIONS—NURSING IMPLICATIONS

Early Prevention of Problems

• Review the patient’s medical record to prepare for your admission assessment (e.g., history of skin conditions, diseases, inherited disorders affecting the skin, or other issues related to skin problems). Plan to ask the patient questions that are not answered by yes or no to describe
  1. Their normal skin tone and any skin changes they have noticed
  2. Unusual sensations they are experiencing (e.g., areas that feel cold or hot, numb, painful, rough, etc.), what makes the sensation worse, and what they do to reduce their discomfort
  3. Their level of nutrition (e.g., what they typically eat at mealtime, how much they eat, and who prepares their meals)
  4. Any mobility issues they have experienced (e.g., trouble getting around, recent falls, or impediments to good/safe mobility in the home)
  5. Self-care issues they have experienced (e.g., incontinence or inability to get to the bathroom in time, wash self, dress self)
  6. Family history of skin issues

A Thorough Skin Assessment Incorporates Inspection, Observation, and Assessment Skin assessments begin after admission and should continue throughout the patient experience as determined by the facility’s protocols. Assessments may be conducted any time there is a change in the baseline admission assessment, such as when there has been a tissue change (e.g., hematoma from a venipuncture, redness around a venipuncture site, or evidence of skin breakdown related to other causes). Pertinent laboratory and diagnostic test results should be reviewed and considered when preparing care plans and performing assessments. Components of the skin assessment usually include

• Color (e.g., blanchable erythema or lack of consistency in patient’s overall normal skin color such as seen with cyanosis)
• Temperature (e.g., using touch to determine whether the skin is cool related to decreased circulation or warm related to inflammation)
• Moisture (e.g., excessive dryness evidenced by tenting, lack of elasticity or excessive moisture evidenced by drainage, incontinence, etc.)
• Integrity (e.g., blisters, breaks in the skin, edema)
• Tissue changes (e.g., simple tears, partial thickness, full thickness)
• Marking of the skin (vascular etiology: erythema, red streaks, petechia, bruising, purpura)
• Lesions
• Use of a validated prediction scale to identify the degree of risk for a pressure injury. There are three main, clinically validated, assessment tools used to predict pressure ulcer risk: Braden, Norton, Waterlow.
• A focus on areas where the patient indicates they are experiencing pain, especially sites predisposed to developing pressure injuries (e.g., bony areas close to the skin surface, skin folds, perineum, areas between the fingers and toes). It is important to connect the complaint of pain to recent activities. Examples might include a venipuncture-induced hematoma that could result in irreversible nerve damage, signs of infection at an IV or venipuncture site, or reddened areas on the patient’s heels after an extensive imaging study that could develop into a pressure injury.
• Review of laboratory study results related to wound development or impairment of wound healing. Clinical test order sets may vary by facility, but many include studies to evaluate nutritional status and to identify and monitor underlying diseases that interfere with immune function and wound healing:
  1. Nutritional studies: Albumin, prealbumin, total protein, transferrin, minerals (e.g., Ca, Fe, Mg), vitamins (e.g., B₁₂, D)
  2. Chemistry studies: Glucose and Hgb A_1C (e.g., chronic elevations related to diabetes lead to microvascular disease, which significantly impairs healing by decreasing the perfusion of oxygen throughout the body and diminishing the normal immune function of lymphocytes); kidney function (BUN, Cr) and electrolytes (Na, K, Cl, CO₂) (e.g., kidney damage is associated with the buildup of uremic toxins, loss of proteins, and increased susceptibility to infection); lipids (e.g., to identify cardiovascular disease, which impairs perfusion of oxygen and distribution of essential nutrients); liver function tests to include ALT, AST, bilirubin, or hepatitis markers (e.g., organ damage that prevents production of proteins crucial to fighting infection and reducing inflammation)
  3. Hematology studies: CBC (e.g., RBC count, Hgb/Hct are associated with anemia; leukocytosis or increased WBC count is associated with infection; thrombocytopenia or decreased platelet count is evidenced by the absence of/delayed platelet response to tissue injury and repair)
  4. Microbiology studies: Culture of tissue, body fluids, or wound sites to identify the infectious organism
• Review of diagnostic imaging study results related to impairment of wound healing may include

1. Plain radiographs, computed tomography (CT), or magnetic resonance imaging (MRI) to identify sites of infection evidenced by the presence of necrotic tissue, ischemia related to conditions that result in insufficient arterial circulation or pressure injuries, underlying diseases that cause microvascular disease (e.g., diabetes)
2. Ultrasound studies of the blood vessels to identify tissue pressure injuries related to arterial or venous occlusion (e.g., where skin covers bony areas such as the ankle, bottom portion of the spine, heel, hip, or knee)
3. Nerve conduction studies to identify loss of nerve response in the rare event of a compression injury related to a venipuncture-related hematoma

Additional Considerations for Skin Assessment of Patients With Pigmented Skin

• Inspection of pigmented skin may not easily reveal a change in skin color (e.g., cyanosis, blanching erythema), tone (e.g., hyperpigmentation), or texture (e.g., an area softer than adjacent tissue, taut, shiny, hard, keloid scarring) that may be indicative of a type I pressure injury. Increased awareness during the assessment of patients with pigmented skin may prevent a treatable injury from advancing in severity before treatment actually begins.
• Consider the use of natural or halogen lighting instead of fluorescent lighting during the assessment; fluorescent lighting can give a bluish-green tint to the skin’s appearance or a gray-white appearance to the skin around the mouth, which presents the potential for misinterpreting observations.

Braden scale—commonly used in the United States. Lower subscale and lower total scores = higher risk. Nursing judgment and scaled elements are combined to include

• Sensory perception (1–4)
• Moisture (1–4)
• Activity (1–4)
• Mobility (1–4)
• Nutrition (1–4)
• Friction and Shear (1–3)