Skin inspection
Tai Li Ling Department of Anaesthesia & Intensive Care
Hospital Kuala Lumpur
Comprehensive skin assessment
•  A process by which the entire skin of the
patient is examined for any abnormalities. •  Inspection and palpation are the keys in skin
assessment.
•  From head to toe, with particular attention
over bony prominences and medical
devices.
Comprehensive skin assessment
•  Perform as soon as possible during
admission (within 8 hours)
•  Repeat on a regular basis based on clinical
setting and degree of risk
–  daily
–  increase frequency in response to overall
deterioration
•  Repeat prior to transfer or discharge
Comprehensive skin assessment
•  Ideally, the daily assessment is performed in
a standardised manner by a single individual
at a dedicated time.
•  Integrate assessment into routine care e.g.
cleaning, or turning the patient.
•  Consistent correct performance of
assessment may be difficult and requires
training and skills.
Comprehensive skin assessment
Some practical aspects:
•  Explain to the patient about the assessment
•  Ensure privacy while performing
assessment
-  minimise exposure of body parts
•  Perform hand hygiene before and after the
examination. Comprehensive skin assessment
Some practical aspects:
•  Remove medical devices e.g. splints,
compression stockings before assessment.
•  If the device cannot be removed e.g. urinary
catheter, the skin around the device must be
carefully inspected.
Comprehensive skin assessment
Some practical aspects:
•  Dark skin tones may be more difficult to
inspect visually. Pay particular attention to
localied heat, oedema and induration. Comprehensive skin assessment
Assessment includes these factors:
•  Temperature
•  Presence of oedema
•  Colour
•  Moisture level
•  Change in tissue
consistency
•  Turgor
•  Localised pain
•  Skin integrity
Skin Temperature
•  use the back of hand rather than the palm to
assess the temperature •  touch the skin to evaluate if it is warm or
cool
•  compare symmetrical body parts for
differences in temperature
•  increased temperature can be a impending
skin problems e.g. Stage I pressure ulcer
Skin Colour
• Ensure that there is adequate light
• Use an additional light source such as a
torchlight to illuminate hard to see skin
areas e.g. sacrum • Know the patient’s normal skin tone to
evaluate changes
• Look for differences in colour between
comparable body parts
Skin Colour
• Depress any discoloured areas to see if they
are blanchable or non-blanchable with
fingertip or transparent disc
Skin Colour
• Blanchable erythema
-  reddened area that temporarily turns white or pale
when pressure is applied
-  early indication of pressure
•  Non-blanchable erythema
–  redness that persists when pressure is applied
–  tissue damage has already occurred (stage 1
pressure ulcer) Skin Colour
• Look for redness or darker skin tone, which
indicate infection or increased pressure
• Changes in colouration may be particularly
difficult to see in dark skin tones Skin Moisture • Touch the skin to see if it is wet or dry, or
has the right level of moisture. • Dry skin may also appear scaly or lighter in
colour. •  Macerated skin from too much moisture
may appear lighter or feel soft/boggy. Skin Turgor • Pinch the skin near the clavicle or the
forearm to lift up the skin from the
underlying structure and then let go. Skin Turgor • If the skin quickly returns to place, this is
normal skin turgor. •  If the skin does not return to place, but stays
up, it is called tenting, and is an abnormal
skin turgor. •  Poor skin turgor is found in patients who are
older, dehydrated, or edematous. Skin Integrity Look to see if the skin is intact •
•  If presence of skin disruption, evaluate for the
following:
–  Abrasion
–  Blister
–  Bruising (due to
pressure)
–  Burn
–
–
–
–
Denuded Laceration
Tear
Wound
Localised oedema/ change in tissue
consistency
•  Indicators of early pressure damage in
patients with dark skin tones
•  Change in tissue consistency includes
induration, hardness Localised pain
•  Ask the patient to identify areas of
discomfort or pain associated with pressure.
•  Incorporate non-verbal cues into assessment
of pain in non-verbalising patients.
•  Pay attention to assessment of these areas. Comprehensive skin assessment
•  Assessment should particularly focus on:
–  areas over bony prominences in relation to
positioning
–  areas related to medical devices
Sitting
Supine
Lateral
Malleolus
Prone
Forehead
Medical device related
•  Inspect skin under medical devices
–  at least twice daily
–  more frequent in those vulnerable to fluid
shifts or with localised or generalised oedema
Practical tips on skin assessment
•  Take advantage of every patient encounter
to evaluate part of the skin.
•  Ask for assistance to turn the patient in
order to examine the patient's back, with a
particular focus on the sacrum.
•  Look at the back of the head during
repositioning. Practical tips
•  When applying oxygen, check the ears for
pressure areas from the tubing. •  When auscultating lung sounds or turning
the patient, inspect the shoulders, back, and
sacral/coccyx region. •  When checking bowel sounds, inspect skin
folds esp. obese.
Practical tips
•  When positioning pillows under calves,
inspect the heels and feet.
•  When checking IV sites, check the arms and
elbows. •  Examine the skin under equipment with
routine removal (e.g. restraints, splints,
oxygen tubing, endotracheal tubes). Barriers to practice
•  Finding the time for an adequate skin
assessment
–  As much as possible, integrate the
comprehensive skin examination into the
normal workflow
–  However, it is a separate process that requires
a specific focus by staff if it is to be done
correctly. Barriers to practice
•  Determining the correct aetiology of
wounds
–  Many different types of lesions may occur on
the skin and over bony prominences. –  Do not confuse moisture-associated skin
changes with pressure ulceration. –  If unsure about the aetiology of a lesion, ask
someone else who may be more
knowledgeable. Barriers to practice
•  Using documentation forms that are not
consistent with components of skin
assessments
–  Develop forms that will facilitate the recording
of skin assessments. Barriers to practice
•  Having staff who do not feel empowered to
report abnormal skin findings
–  Communication among nurses, clinicians and
nursing sisters is critical to success. How can practice be improved? •  Comprehensive skin assessment requires
considerable skill.
•  Provide training for all staff •  Ask a colleague to confirm skin assessment
-  having a colleague evaluate the skin
assessment will provide feedback as to how
one is doing and help correct documentation
errors. How can practice be improved? •  Perform skin assessments with an expert. -  Consider having an expert from another unit
round with unit staff to confirm findings from
the comprehensive skin assessment. •  Ask for clarification when one is unsure of
a lesion. -  Take advantage of the local wound care team or
other staff who may be more knowledgeable. How can practice be improved? •  Use available resources to practice to
differentiate the aetiology of skin and
wound problems. Documentation
•  Document the findings of all comprehensive
skin assessments
•  Communicate these findings among staff
•  Keeping a separate log book that
summarises the findings of all
comprehensive skin assessments of all
patients in the unit
•  file://localhost/Users/taililing/Desktop/
Pressure ulcer/www.mha-apps.com-mediaVTS_01_1.html.flv