1. UCSD SKIN ASSESSMENT & DOCUMENTATION
Cheryl Garnica RN, CWOCN
Spring 2011

2. SKIN TRENDS AND REGULATION CHANGES
2007:
Changes by CMS for payment of HAPUs
NUAP new definitions for pressure ulcers
Addition of Pressure Ulcer Stages: Unstageable and Deep Tissue Injury
2009:
Clarification of MMPs (mucous membrane pressure ulcers: do not fit in staging guidelines
Best practice/evidence based guidelines published by NPUAP and EPUAP

3. REGULATION & REPORTING CHANGES
POA defined (Present on Admit)
Medicare payment changes: Stage III , Stage IV, Deep Tissue injuries and unstageable HAPUs: Possibly no $$monetary compensation
CDPH: MUST be notified within 5 days of finding HAPPU Stage III, IV, Unstageable and DTI present on admit that converts to unstageable eschar

4. Who Stages Pressure Ulcers??
ANA position Statement 2010: Nurses!!
BUT: you must be able to differentiate between pressure ulcers and other types of wounds
Physicians

5. RESOURCES FOR SKIN CARE AT UCSD
Skin Team Champion
CNS/Clinical Nurse Educator
WOCN MD
Wound Manual
Skin Standards on Web Ref
Cal Noc Tutorial: User ID: tuto620
Password: tuto634
PU learning modules

6. Skin Facts Largest organ Often reflects patient’s general condition
First line of defense against moisture, pathogens
Thermoregulation
Sensory
Metabolism (Vit. D)
Communication

7. Changes with aging Less fat, collagen: decreased elasticity
Decreased sensation
Decreased thermoregulation
Decreased ability to fend off pathogens

8. Factors that alter skin integrity
Nutrition
Age
Disease State
Hydration
Medications
Sensory Impairment
Mental Impairment
Immobility
Incontinence
Circulation

9. SKIN: NURSES RESPONSIBILITY
Promote and maintain skin integrity
Assess and Identify risk factors: for skin impairment
Implement Interventions: to prevent skin breakdown
Document: findings & interventions
Communicate: to physicians and staff
Educate: family re: Breakdown prevention and treatment

10. Skin Assessment: Frequency
On admit, within first hour
Every shift
Transfer to unit
Change in condition or level of care
Post procedure
Reassessment: every position change

11. Methods of Skin Inspection
Visual and Touch
Head to toe inspection
Particular attention to boney prominences: occiput, spine, shoulder blades, elbows, sacrum, coccyx, heels, trochanters, Maleolus, ischeum
In skin folds (especially with Bariatric patients)
Check under medical devices

12. Pressure points to check

14. What to assess??
Color: blanchable, pale, redness; dark skin may require flashlight for assessing at risk pressure areas
Intact or not?
Turgor (resilience, hydration)
Temperature: warm, cold
Moisture: incontinent, sweating, dry, flakey
Texture: hard, soft, boggy, mushy, induration, blistering
Existing skin issues: wounds, rashes, bruises, skin tears, ecchymosis

15. BRADEN SCALE Identifies Risk Factors Contributing to Skin Breakdown
Sensory
Moisture
Activity
Mobility
Nutrition
Friction and Shear
18 or less: MUST HAVE CARE PLAN

16. BRADEN SCALE:
Completed every shift and on change in condition or level of care
Low scores on Braden subscale: should drive your care plan and interventions for skin care

17. FINDINGS ON ASSESSMENT
Skin alterations, open wounds: Identify source (pressure, skin tear, shear, abrasion, surgical wound, venous or arterial ulcers, trauma, etc.
Get a history from the patient
Describe what you see

18. Is it a pressure ulcer? Definition:
Damage caused to skin and underlying soft tissue by unrelieved pressure when the tissue is compressed between a bony prominence and external surface over a prolonged period of time
3 main contributing factors in formation: Pressure, Shear and Friction
Most pressure ulcers are over a bony prominence, however, they may be present over soft tissues.
Keypoint: assess over bony areas AND under medical devices (SCDs, oxygen prongs and tubings, foleys, drains, objects left in bed, etc.)

19. STAGE I
Intact skin with non-blancheable redness of a localized area usually over a boney prominence. Darkly pigmented skin may not have visible blanching; its color may differentiate from the surrounding area.
Keypoint: dark skin individuals: inspect skin for warmth, coolness, induration (firm, hard) or boggy areas. May be painful.

20. Stage I

21. Stage II
Partial thickness loss of dermis which may present as a shallow crater, NO SLOUGH (yellow dead tissue). May also present as a serum filled blister (intact or ruptured).
Keypoint: dermal depth, all pink, shallow; do not use Stage II to define skin tears

22. Stage II

23. Shear effect with pressure

25. Stage III
Full thickness tissue loss. Subcutaneous fat may be visible. Bone, tendon or muscle NOT exposed. Slough may be present, but does NOT obscure the depth of tissue loss. May include undermining and tunneling.
Keypoint: amount of subcutaneous tissue varies per anatomical area and per individual. Thin folks: little subcutaneous tissue whereas morbidly obese may have excess

26. Stage III

27. Stage IV
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Keypoint: Depth of tissue loss varies per anatomical location. Bridge of nose, ear, occiput and malleolus have little or no subcutaneous tissue; these Stage IV ulcers CAN BE SHALLOW

28. Stage IV

29. Unstageable
Full thickness tissue loss in which the base of ulcer is covered by slough (yellow, tan, gray, green, brown) and/or eschar (tan, brown or black) in the wound bed.
Keypoint: until enough slough/eschar is removed to expose the base of the wound, you can not accurately stage it; therefore, it is unstageable

30. Unstageable

31. Deep tissue injury
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear. Area may be preceeded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may appear as a thin blister over a dark wound bed, may progress to eschar and further opening. Depth unknown. May or may not be reverseable.
Keypoint: must monitor carefully. Use NON- adhesive dressings to protect.

32. Deep Tissue Injury

34. Mucous membrane ulcers: don’t stage; describe what you see

35. Intertrigo
An inflammatory condition of the skin with our without skin loss in skin folds induced or aggravated by mechanical friction, maceration, moisture, heat. May have bacterial or fungal component. Often found in skin folds, axilla, gluteal fold, perineal area, abdominal panus, under heavy breasts. Morbidly obese high risk in skin folds.

37. Intertrigo with fungal infection

38. DOCUMENTATION PADB: Chronic skin issues??? YES!!
Further elaboration should be in note and on skin assessment
Basic skin condition: moist, dry, flakey, skin turgor, ecchymotic, paper thin skin
If wounds found on admit, ASK the pt. how, where, when acquired and DOCUMENT

39. DOCUMENTATION:WOUND CHARACTERISTICS
MUST include: location, type of wound, color or general appearance of wound base (pink, red, slough, eschar, etc.)
Describe surrounding skin (intact, macerated, red, hard, moist, etc)
Measurements: on finding wound and weekly
Drainage (amount, character, color, odor or lack of odor)
PAIN!! Presence or absence

40. DOCUMENT YOUR INTERVENTIONS
Treatment done or condition of dressing if not changed
Who notified
Pain level/analgesia offered or given/response
Pressure Ulcer prevention interventions/consults (WOCN, PT, OT, nutrition, turning, pressure offloading, specialty boots, specialty mattresses, Geomatt)
Document education done with patient and family

41. CARE PLAN Patient/individual specific (difficult with EPIC)
Measureable outcomes/Realistic
Interventions: specific for patient vs. canned responses
Special attention to Braden Scale using subscales with low scores : address in care plan interventions
Document who was notified if unusual findings
EVALUATE: is the treatment working?? If not, what should you change? Address!

42. Current Treatment Specific Standards you can implement NOW
Incontinence: Baby wipes, skin cleanser, skin barriers, moisturize with lotion, fecal pouches
Offload pressure: Prevalon boots, pillows for bridging and turning, turning schedule, Geomatt cushion for sitting
Resource utilization: WOCN, MD, CNS/Educator, Skin Champion

43. Nursing Interventions: No orders required:
Stage I Options: open to air, dry dressings, Tegaderm, Allevyn, Alleyn Non-adhesive, skin prep
Stage II: Allevyn, Allevyn non-adhesive, Tegaderm, use of Solosite Gel if wound bed dry in addition to cover dressing
DeepTissue Injuries: Open to air (dry, non blistered); Allevyn NON-adhesive if blistered or thin skin coating and at risk with adhesives, Elastogel

44. Skin Tears: Superficial
Xeroform or Vaseline gauze/Kerlix. AVOID adhesives. Change every 1-2 days depending on drainage.
Deeper tears or flap tears: extensive tissue damage and need MD or WOCN consult

45. Wound Wednesdays
Wounds that have dressing orders should be measured, photographed and documented weekly; Wednesdays preferred.
Fill out EPIC wound documentation, upload photo. You may document below photo or in care plan notes.
Notify MD of findings, can click “cosign” to alert to photo

46. Are you an expert yet???

50. THE END!!