Skin Assessment

 Skin Assessment should be performed during admission and discharge to/ from the hospital, every shift, if Pt. conditions change, and at the emergency department. 

Complete assessment of the skin head to toe, paying attention to bony prominence because there can be the site for a pressure injury, aka bed sore. those are the most frequently bony prominences: 

*Sacrum/coccyx

*Buttocks

*Ischium

*Heels

Braden scale: Braden scale is a standardized and validated tool to determine pressure injury risk, It contains 6 items, sensory perception, moisture, activity, mobility, nutrition, and friction and shear. These helps in the decision-making and plan of care.

Assessing pressure related changes like temperature, cooler, warmer, blanch response, and pain or discomfort. Signs of pressure injury may include blanchable erythema, and or changes in tissue temperature or consistency.

"Blanchable" refers to an area of skin redness that turns white when pressure is applied, meaning the color disapears with pressure, while "non-blanchable" means the redness persists even when pressure is applied, indicating potentialtissue damage and often a sign of developing pressure ulcer. in dark skinn colors apply a wet wipe and use a tangential lighting, use a penlight to detect suspected erythema or color changes. 

Complete skin assessment include 

Skin Tones:  

*Pallor (paleness)

*Erythema (redness)

*Ecchymosis (bruising)

*Jaundice (yellow)

*Cyanosis (blue)

*Mottling ( spotty white)

Turgor:

When skin on the back of the hand is pinched, it should immediately return to normal. A variation of this may be indicative of dehydration or aging.

Temperature

Moisture

Skin Integrity:

* Intact

*Breakdown: open areas (skin tears, pressure injuries)

* Rash (fungal, bacterial)

*Moles, Freckles, variation in skin color or texture

Braden subscale: Sensory Perception

1) Completely Limited : unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body. Ex : comatose, sedated and intubated patient

2) Very Limited : responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Ex: Spinal cord injury below the waist, stroke with hemiparesis.

3) Slighly Limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits the ability to feel pain or discomfort in 1 or 2  extremities. Ex: Patient has diabetes and has neuropathy (can't feel pain in their feet)

4) No Impairment: responds to verbal commands. has no sensory deficit to feel or voice pain or discomfort.

Braden Scale Mobility: 

1) Completely Immobile: Does not make even slight changes in body or extremity position with assistance

2) Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3) Slightly Limited: Makes frequent though slight changes in body or extremity position independently.

4)No limitations: makes major and frequent changes in position without assistance.

Avoid : Egg mattresses, turning pacient onto a body surface that is still red from a previous episode of pressure loading.

Braden Scale Activity: bedfast, chairfast, walks occasionaly, no impairment. Avoid: long periods sitting, donut-type devices.

Braiden Scale Moisture: completely moist, very moist, slightly moist, rarely moist. Avoid hot water, plastic underpads, multiple layers of linens under patient, briefs in bed.

Recommended Interventions: turn and reposition every 2 to 3 hours, if unable to tolerate full turns, frequent micro turns every hour until stable. Heels if reclined, elevate off of footrest. Sacrum/lowe buttocks:consider application of multilayer foam dressing with silicone adhesive. Support surface: consider reactive overlay (specialty bed) or "sand bed" 

Braden scale Nutrition:

1)Very Poor: never eats a complete meal . Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly.. Does not take a liquid dietary supplement OR is NPO and or maintained on clear liquids or IVs for more than 5 days.

2) Probably Inadequate rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

3) Adequate eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutricional needs.

4)Excellent eats most of every meal never refuses a meal Usually eats a total of 4 more servings of meal and dairy products. Occasionaly eats between meals. Does not require supplementation.

Recommended Interventions: consult dietician if: NPO for more than 48 hrs, presence of stage 2 or greater pressure injury.

Braden Risk Category: Friction and Shear

Friction: occurs when the skin moves against another surface. Ex pulling a patient up in bed, pulling linens/tubes out from under patient, using elbows to push self up in bed.

Shearing: the pulling of two adjacent tissues in opposite directions,often resulting in tissue destruction Ex: High risk of shearing when HOB>30 degrees. Tissue and superficial fascia remain fixed against the bed linens while the deep fascia and skeleton slide down toward the foot of the bed causing deeper tissue injury.

Probem, potential problem, no apparent problem Avoid greater than 30 degrees head of the bed elevation.

Final notes: this entire presentation is from the mandatory courses provided by Ascension Seton, they are all standard tools to follow. The computer Cerner charting, program will give the score imediately when data is entered during charting. The only purpose of this presentation is educational purpose only.