A thorough skin assessment gives you
important information about potentially serious diseases
, especially in older adults who are vulnerable to skin breakdown.
Why do you need to carry out a skin assessment and what are you looking for?
A skin assessment needs to be
repeated whenever a person is identified as at high risk as a result of a pressure ulcer risk assessment
, to take account of any changes to the skin and to ensure patient and service user safety.
Why is skin assessment important for you as a nurse?
To identify patients at risk for skin failure, assessment should be conducted on
admission to the ward to identify any issues with the skin’s integrity
such as existing wounds (especially pressure injuries) or vulnerable pressure points, excoriation and rashes.
Why is assessing the skin so important upon admission and frequently thereafter?
If the person has a wound it is important to assess the surrounding skin. This helps you decide if the wound is improving, stalled or deteriorating. Determine if the skin
shows blanching, blistering, dryness, ecchymosis or erythema surrounding it
.
What is the purpose of conducting a skin and risk assessment?
Risk screening and risk assessment of skin integrity generally refer to the same process, which is used to identify patients who are at risk of developing skin problems or who have skin problems. The results of screening or assessment are
used to inform the implementation of prevention and management strategies
.
What happens in a skin assessment?
A skin assessment should include an
actual observation of the entire body surface
, including all wounds*, inspection of hair, nails, skin folds and web spaces on hands and feet, systematically from head to toe.
How is a skin assessment carried out?
Perform a
physical assessment
This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present.
What does skin breakdown look like?
Skin breakdown starts out as a
red or purple spot on fair skin
or a shiny, purple, blue or darker spot on dark skin, which does not fade or go away within 20 minutes. When you press on the spot with your finger, it does not become lighter (blanch). It may feel warmer or cooler than the skin around it.
Nursing responsibilities related to skin integrity involve
assessment of the patient and the wound
(Fundamentals Review 8-3), followed by the development of the nursing plan of care, including the identification of appropriate outcomes, nursing interventions, and eval- uation of the nursing care.
What does skin integrity mean?
Skin integrity refers to
skin health
. A skin integrity issue might mean the skin is damaged, vulnerable to injury or unable to heal normally. A pressure wound (also called a pressure sore, bed sore or pressure ulcer) is an injury to the skin and surrounding tissue.
How often should skin assessments be done?
3.2. 3 How frequently should comprehensive skin assessments be performed? Comprehensive skin assessment is not a one-time event limited to admission.
It needs to be repeated on a regular basis
to determine whether any changes in skin condition have occurred.
What does a Braden score of 19 mean?
The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk is for developing an acquired ulcer or injury. 19-23 =
no risk
. 15-18 = mild risk. 13-14 = moderate risk.
How do you know if you have skin turgor?
To check for skin turgor,
the health care provider grasps the skin between two fingers so that it is tented up
. Commonly on the lower arm or abdomen is checked. The skin is held for a few seconds then released. Skin with normal turgor snaps rapidly back to its normal position.
How does age affect skin integrity?
Older adults are at a higher risk because of the skin aging process. As skin ages, the junction between
the epidermis and dermis thins and flattens
, reducing circulation. Moisturizing factors in older adults also reduce, thus causing dry, flaky skin and increased risk of skin breakdown.
What is the falls risk assessment tool?
A falls risk assessment involves
using a validated tool that has been tested by researchers to be effective in specifying the causes of falls in an individual
. As a person’s health and circumstances change, reassessment is necessary. … There is no one falls risk assessment tool recommended for use in all situations.
Why is skin integrity important?
Good skin integrity is vital to good health because
the skin acts as a barrier to microbes and toxins
, as well as physical stressors such as sunlight and radiation. It is well known that the skin loses integrity with the ageing process, and this makes older adults susceptible to pressure injury.
