Head to Toe Skin

Assessment
Karen R. Brown BS, RN, CWS
Wound/Ostomy Specialist

Objectives:
Describe

essentials for maintenance

of healthy skin
Discuss pressure ulcer risk
assessment tools
Describe appropriate documentation
of skin assessment

SKIN ASSESSMENTS

Each square inch of

human skin consists
of twenty feet of
blood vessels

A large amount of the dust in you

home is actually dead skin

Humans shed about

600,000 particles of
skin every hour about 1.5 pounds a
year. By 70 years of
age, an average
person will have lost
105 pounds of skin.
A large amount of the
dust in you home is
actually dead skin

Skin Facts

Skin assessment
important in the prevention of pressure ulcers, IAD,
MADS,Intertrigo, etc.
A complete skin assessment should include:
Assessing for localized heat
Edema
Induration (hardness)
Excessive moisture

Skin Assessment

Skin Care

is important to protect the skin

from breakdown:
Not massaging skin
Not turning the patient back onto
a still reddened surface from
previous pressure loading
Not vigorously rubbing skin that
is at risk for skin breakdown

SKIN ASSESSMENT

What tools do we use?

Eyes
Hands
Ears
excellent history taking and data gathering
Braden Scale
Nutrition Assessment Tool

CONFINED TO BED/CHAIR
Preventative

Actions

Look

at skin at least
once a day.

Bathe

only when
needed for comfort or
cleanliness.

Prevent dry skin.

Immobility/decreased mobility

For a person in a chair:

1. Change position every hour
or as often as possible.
2. Use foam, gel, or air cushion
to relieve pressure.
Reduce friction by:
Lifting, rather than dragging,
when repositioning.
Using cornstarch on skin.

Involve physical therapy as

needed.

SKIN ASSESSMENT

Donuts
are for
eating
Not sitting
on

NO DONUT SHAPED CUSHIONS

Change position
at least every 2
hours.

Use a special
mattress that
contains foam,
air, gel, or water.
Raise the head
of bed as little
and for as short
as a time as
possible.

For a Bed Bound Patient

Loss of Bowel or Bladder Control

Clean skin as soon as soiled
with urine or stool.
Assess and treat urine
leaks.
If moisture cannot be
controlled:
1. Use absorbent pads and/or
briefs with a quick-drying
surface.
2. Protect skin with a cream
or ointment.

Poor Nutrition

Eat a balanced diet.

If a normal diet is not
possible, talk to health
care provider about
food supplements

Lowered Mental Awareness

Choose preventative
actions for the person
with lowered mental
awareness. For example,
if the person is chairbound, refer to the
specific preventative
actions outlined in Risk
Factor 1.

Support Surfaces

SKIN ASSESSMENT
DOCUMENTATION

SKIN
ASSESSMENT
SKIN FOLDS
DOCUMENT
PRESENCE OF:
MOISTURE
RASH
CANDIDA
LESIONS

2007 Medline Industries, Inc.

Xerosis is a
dermatosis
exhibited as dry
scaly skin with or
without erythema
(redness) and
pruritus (itching)

xerosis
Caused by epidermal
water loss
Loss of natural
moisturization
factors
LOCATION:
Usually lower legs
Sometimes trunk and
hands

xerosis
Clinically looks like
Scaling, flaking skin
Dull, white color and
increased skin
markings

DOCUMENT
changes in skin
color
excess skin
moisture
skin turgor
changes in skin
texture

SKIN
ASSESSMENT
DOCUMENT ULCER
LOCATIONS OVER
BONY PROMINENCES

HISTORY OF
PREVIOUS
ULCERATIONS

SKIN ASSESSMENT

PALPATE FOR
WARMTH,
TENDERNESS,
BOGGINESS
EDEMA
DOCUMENT EVERY
DETAIL

ASSESS MEDICAL
DEVICES
DOCUMENT
TYPE OF DEVICE
LOCATION
TYPE OF
SECUREMENT
DEVICE

ASSESS MEDICAL
DEVICES

TUBE SITE EROSION

HYPERGRANULATION
TISSUE

BARIATRIC
SKIN
ASSESSMENT
incontinence-related
dermatitis secondary to
inability to perform
personal hygiene,
pressure ulcers
(including sites other
than bony
prominences),
venous
Insufficiency/ulceration,
and/or lymphedema.

BARIATRIC SKIN
ASSESSMENT
The bariatric patient
may not be able to
clean the perineal
area well enough or
maybe not at all.

BARIATRIC SKIN
ASSESSMENT
Pressure ulcers not
over bony
prominences
Increased propensity
for venous ulcers
with or without
lymphedema
Malnourishment

INCONTINENCE
ASSOCIATED
DERMATITIS (IAD)

Incontinenceassociated dermatitis
is a common problem
affecting as many as
half of the patients
with urinary or fecal
incontinence who are
managed with
absorptive
products.

SKIN CARE PROTOCOLS

Clean after soiling

and at routine
intervals

Avoid hot water

Use mild cleansers

non- irritating and
non-drying agents

Use moisturizers
for dry skin

Use

barrier
ointments/ sprays
Powder

bedpans

SKIN CARE PROTOCOL

Use heel/elbow protectors or
socks
Use lift sheets or pads to move
patient
Limit head elevation to 30
degrees and use knee gatch if
available
Use overhead trapeze (prevent
dragging patient up in bed)
Use footboards
Use light weight clothing and
covers (layering is best)
Minimize environmental factors
leading to drying such as low
humidity/exposure to cold

References
Gray M, Ratliff C, Donovan A. Perineal skin care for the
incontinent patient. Adv Skin Wound Care.
2002;15:170-179.
Ghadially R. Aging and the epidermal permeability barrier:
implications for contact dermatitis. Am J Contact Dermat.
1998;9(3):162-169.
Brown DS. Perineal dermatitis risk factors: clinical validation of
a conceptual framework. Ostomy Wound
Manag.1995;41(10):46-48, 50, 52-53.
European Pressure Ulcer Advisory Panel and National Pressure
Ulcer. Treatment of pressure ulcers: Quick Reference Guide.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.

References

Portable Instructional Education (PIE). Home Health

Care 1st Edition. (CD) Wound Ostomy and Continence
Nurses Society, WOCN National Office, Mt. Laurel, NJ;
2008.