Back to Basics: Skin Assessment Training. Speaker: Joanne T. Wheaton APRN, FNP-C

Transcription

1 Back to Basics: Skin Assessment Training Speaker: Joanne T. Wheaton APRN, FNP-C

2 LEARNING OBJECTIVES: 1. Learn the basic anatomy and physiology of the skin, how to assess the skin, identify the differences between normal or abnormal skin observation, evaluation of the skin changes, and documentation and reporting of the assessment. 2. At the end of the presentation, the dialysis nurses and patient care technicians would be able to properly assess and differentiate between normal and abnormal skin observation, identify the importance of good skin assessment, identify proper techniques to care for the skin, and be able to educate the patients about access skin care in the clinical setting.

3 The Skin TRUE OR FALSE: 1. The skin covers the entire body accounting for approximately how many percent of the body s weight? a. 2% to 3% b. 16% to 20% c. 30% to 40% d. 50% The skin is the body s largest organ. So if your patient s weight is 100kg, approximately 16kg to 20kg is the weight of the skin.

4 The Skin 2. The primary function of the skin is to: a. Protect the body from the environment by serving as a barrier against microorganisms, ultraviolet (UV) radiation, loss of body fluids, and the stress of mechanical forces. b. Regulates body temperature within a narrow range and is involved in the production of Vitamin D. c. Touch and pressure preceptors provide protective functions and sensations. d. All of the above

5 So what do we do when patients come in for treatment? 1 Inspect for skin color, uniformity, thickness, symmetry, hygiene, lesions, and odor (uremic smell). 2 Palpate skin for moisture, temperature, texture, and turgor. 3 Symptoms to look for: bleeding, swelling, bruising, redness, drainage, and pain. 4 Commonly, we look at the access site for it s general appearance (length, size, and shape of the AVF or AVG), any signs and symptoms of infection, and presence of swelling or edematous areas of the body.

6 Skin Integrity This is the overall health of our skin. Good skin integrity is important to protect everything that is inside our body. Breakage or damage to the skin allows bacteria, viruses, or microbes to enter the underlying tissue or blood stream.

7 Skin integrity Normal flora are bacteria that are harmless and usually reside on our skin s surface. However, if they enter the body, they can cause infection and other complications. There are around 1000 species upon human skin from nineteen phyla (a label used to group living things together based on common features). The skin usually has Gram-positive organisms (e.g., staphylococci, micrococci, diphtheroids). Inspection of access site: previous needle sites would have scabs over it and are part of the healing process. Scabs are not to be removed or manipulated unless you re using a buttonhole technique.

8 Skin Integrity Inspect for presence of dryness, rashes, excoriations, scratches, drainage/exudate, sores, unusual lumps, amount of perspiration, and presence of lesion that does not heal or is chronically irritated. There should not be any erosions over the vessels of the access. Fistula might be prone to access rupture (very dangerous!). Cannulation should be away from the rashes, excoriations, scratches, or drainage or lesion areas. It is best to notify the nephrologist/np/pa, so proper treatment can be obtained for the drainage or lesions.

9 Skin color and temperature There are variations of skin color but should be of normal skin tones. Presence of discoloration such as redness, pale skin, blue or blackened could mean any conditions. Redness inflammation or infection Pale skin poor circulation or decreased blood supply in the area

10 Skin color and temperature Blue or blackened bruising, injury, or no blood supply on the skin area at all ( e.g., necrosis) The skin should feel warm to touch. Hot fever or presence of infection Cold/Cool poor circulation, low blood pressure ( cold and clammy), low blood sugar

11 What if the patient has pain, numbness, or swelling? Pain should not have any pain at the access site or the limb involved. Investigate the location, frequency, duration, onset, how the pain started, and what relieves it. Needs to be referred to the nurse and the doctor. Numbness you can t see numbness but patients can verbalize this symptom. Possible poor circulation or interruption of blood flow (e.g., stenosis, steal syndrome) Steal syndrome - refers to vascular insufficiency resulting from an arteriovenous fistula or synthetic vascular graft-av fistula.

12 Allen s test (Steal syndrome) If the normal color of the hand returns within five to seven seconds, then both arteries are supplying blood to the hand and the test is negative. The test is positive if it takes over seven seconds for the hand to return to its normal color. A positive result indicates that there is only one artery delivering blood to the hand.

13 Edema Swelling/Edema most common. Pitting or nonpitting. Of the total fluids in the human body, 2/3 reside inside the cell (intracellular fluid) and 1/3 outside the cells (extracellular fluid or ECF). Meaning, patients with edema have an excess of ECF. ECF has 2 compartments: vascular area and the area in between the cells but outside of the vascular compartment ( interstitial fluid). If you apply a digital pressure on the skin and leaving an indentation, this is described as pitting edema. This demonstrates that the excess interstitial fluid can move freely within its space between the body s cells. Nonpitting edema is when the interstitial fluid cannot move freely (e.g., chronic venous stasis or lymphedema).

14 Question: Patient Z came in to dialysis unit and been scratching the surrounding area of his right IJ catheter site. He was noted to have rashes on his right chest and on his body trunk. He also said that they are painful. The PCT informed the nurse about the rashes. Nurse verbalized, Your Phosphorous level is at 8.0, so you are going to be scratching yourself most of the time unless you bring that Phosphorous level down to normal. The rashes continued to get worse and painful, patient sought help in the ER. What could possibly be the cause of the rashes?

15 Hyperphosphatemia Elevated Phosphorous level. Dialysis patient goal level: 3.5 to 5.5 Are your patients taking their binders? Are they taking it properly?

16 What do you think caused the rashes?

17 Shingles According to CDC, almost 1 out of every 3 people in the United States will develop shingles, also known as herpes zoster, in their lifetime. Anyone who has recovered from chickenpox may develop shingles; even children can get shingles. The risk of shingles increases as you get older. Some people have a greater risk of getting shingles: with medical conditions that keep their immune systems from working properly like cancers (leukemia and lymphoma), HIV, and those who receive immunosuppressive drugs, e.g., steroids and drugs that are given after organ transplantation.

18 Shingles Most people who develop shingles have only one episode during their lifetime. However, a person can have a second or even a third episode. Shingles is caused by the varicella zoster virus (VZV), the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays dormant (inactive) in the body. Treated with antivirals, analgesics, antihistamines. Vaccination available.

19 Scabies Scabies is an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies.

20 Scabies Scabies can occur on any part of your body, but there are certain areas that they are more likely found. Scabies burrows or tracks are typically found in the folds of skin: Between fingers In armpits Around the waist Along the inner arm, especially the wrist and elbow On the bottoms of feet Near the breasts Near male genitalia On the buttocks On knees Around the shoulder blades

21 Bed Bugs

22 Bed Bugs Feed on blood as their only source of nutrition. Blood spots found on one s sheets, bites and the presence of bed bug feces and cast skins are some of the indications of a bed bug infestation. Bites are commonly found on the parts of the body that are more likely to be exposed to bed bugs during sleep the hands, neck, face, shoulders, legs and arms. While not always the case, bed bug bites are often grouped together in a small area and at times may occur in a line or a zigzag pattern. Bites normally look like small, flat or raised areas that may become inflamed, itchy, red or blistered.

23 Calciphylaxis/calcific uremic arteriolopathy (CUA) a rare and serious disorder that presents with skin ischemia and necrosis and is characterized histologically by calcification of arterioles in dermis and subcutaneous adipose tissue. calcium accumulates in small blood vessels of the fat and skin tissues. Calciphylaxis causes blood clots, painful skin ulcers and may cause serious infections that can lead to death. Treated with Sodium Thiosulfate

24 Documentation Include in the documentation what you have observed: 1. Skin changes: Color, symmetry, odor, temperature, dryness, pruritus, sores, rashes, lesions that do not heal or is chronically irritated 2. Temporal sequence: date of initial onset, time sequence of occurrence and development; sudden or gradual onset, date of recurrence 3. Symptoms: itching, pain, exudate, bleeding, color changes, seasonal or climate variations. 4. Location: skinfolds, localized or generalized.

25 Documentation 4. Associated symptoms: presence of systemic disease or high fever, stress related 5. Recent exposure to drugs or environment or chemicals 6. Travel history: where, when, length of stay, exposure to other diseases 7. Medications: new, topical preparations, antibiotics

26 Patient Education 1. Using good lighting when checking the skin. Look for a new growth or skin changes. 2. Ask a friend or relative to help with looking at difficult areas like the back and scalp. 3. Skin care habits: cleansing routine, soaps, oils, lotions, sun exposure habits, use of sunscreen. 4. If with contagious disease, to isolate belongings/self while active with the disease. Follow dialysis clinic s policy and procedure. 5. Healing response might be slower for older adults especially with diabetes or PVD. 6. Follow up with PCP for further management/treatment.

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