CHAPTER 6 Skin and wound inspection and assessment

1. Differentiate between skin inspection and skin assessment.

2. List six factors to consider when assessing darkly pigmented skin.

3. Distinguish between wound assessment and evaluation of healing.

4. Define partial-thickness and full-thickness tissue loss.

5. Compare and contrast a normal and an abnormal finding for each wound assessment parameter.

6. Describe how to measure the length, width, depth, tunneling, and undermining of a wound.

An initial skin and wound assessment provides the foundation for developing a patient’s plan of care. However, ongoing skin and wound assessments also are critical because they provide the mechanism for monitoring the effectiveness of that plan, thus allowing determination of progress or deterioration of the wound. Documentation of assessment findings facilitates communication among caregivers. Because of the myriad etiologic, systemic, and local factors commonly involved in the pathogenesis of a wound, a comprehensive patient assessment is essential to identify cofactors that may impair wound healing and jeopardize skin integrity. Whereas all patients with or without wounds require a skin assessment upon admission, the patient with a wound requires additional assessments, including underlying causes for the wound and healing impediments.

Significance

In order to adequately convey the condition of a wound or a skin lesion, wound and skin assessment requires access to a unique vocabulary. As with monitoring blood pressure, temperature, and pulse rate, those attending to a wound preferably should use objective parameters to reflect its present status. However, the state of the science is such that both subjective and objective measures are required to adequately capture the condition of the wound. Because subjective measures by definition can vary in interpretation from one user to another, it is essential that accurate use of wound assessment terminology be emphasized in staff education and that competencies for wound and skin assessment be used (Appendix C).

The economics of health care impose additional motivation for conducting and documenting a systematic measurement of wound healing. Without objective criteria of the status or progress of repair, it is difficult to justify treatments or assign appropriate reimbursement for services. The standard of care is to provide accurate and routine skin and wound assessments. Failure to assess the patient systematically also carries a great legal liability risk (Murphy, 1996). Without accurate, consistent, and retrievable documentation, it is very difficult to retrospectively create a clear picture of the patient’s condition and of the care that actually was provided.

Assessment

Assessment is a two-step process that requires inspection and collection of data and then interpretation of that data so that a plan of care can be derived. During the initial encounter an assessment provides the baseline data to which comparisons can be made to determine changes; this is the process of monitoring.

The word assessment alone as it relates to the prevention and management of wounds can be confusing because a number of assessments are required: risk assessment (see Chapter 8), skin assessment, wound assessment, and physical assessment. For clarity and safety, findings from each type of assessment must be documented using appropriate terms to describe the patient’s skin or wound condition. Staff education should include how to conduct the assessments and how to link appropriate interventions to the findings.

Skin inspection and monitoring

Skin inspection involves data collection related to skin changes based on visual observation. A complete skin inspection must be completed by trained staff upon admission (for baseline data) and daily. It is important to inspect all of the skin from head to toe (WOCN, 2010). An adequate skin inspection requires the removal of garments (including shoes and stockings) and effective positioning for optimal visualization. Staff conducting the inspection will need to gently spread skin folds (including the buttocks), check between the toes, and remove or reposition medical devices to inspect for pressure-related skin damage from devices such as oxygen tubing, nasogastric tubes, urinary tubing, drainage tubing, therapeutic stockings, and splints. Staff performing the skin inspection should be expected to report the overall skin condition, such as change in skin condition (e.g., intact, broken, denuded), skin color (e.g., red, dusky), texture (e.g., pinpoint macular–papular rash, dry skin), and wounds. These findings then are communicated to a registered nurse or a physician for interpretation and additional information collected as needed to further describe and understand the present condition.

The skin and wound condition should be monitored on a routine and regular basis as defined by the facility policy and the severity of the condition. Monitoring allows the staff to keep track or “watch” for changes that deviate from the baseline data. For example, 3 days after admission, a reddened area is identified through routine monitoring, while the baseline assessment and documention indicated no redness upon admission. The new finding should prompt further assessment to identify etiology so that modifications to the plan of care can be implemented. Part of the plan of care will include continued monitoring and perhaps more frequent repositioning.

When dressings are in place and do not require changing, the dressing should be monitored for intactness and the surrounding skin inspected for the presence or absence of discoloration (erythema, bruising), rash, break in skin integrity, and pain (van Rijswijk and Lyder, 2005). Narrative documentation can be as simple as “dressing dry and intact, surrounding skin within defined limits,” or a flow chart can be used (Appendix B).

Therefore, monitoring can occur independent of dressing change. However, if the dressing is leaking or new observations are made (swelling, pain, erythema), the dressing should be removed and a thorough wound assessment obtained. Monitoring usually occurs more frequently than an assessment or head-to-toe skin inspection, for example, every 8 hours in the acute care setting or every day in the long-term care setting. To conserve staff time and patient energy, monitoring and skin inspection can be conducted at the same time that other routine cares are provided (Table 6-1).

TABLE 6-1 Routine Activities Coordinated with Skin Inspection

Routine Activity	Skin Inspection Site
Oxygen application	Back of ears and bridge of nose
Retaping or securing nasogastric tube	Nares
Tracheotomy care	Neck (under ties or strap)
Listening to lung sounds	Occiput, spinous process, scapula, coccyx, and sacrum
Listening to bowel sounds	Between and under skin folds of pannus and groin
Placing pillows under calves	Feet, heels, toes
Application or removal of antiembolism stockings or splints	Feet, heels, toes
Intravenous site care	Elbows and arms
Transferring in or out of chair	Coccyx and sacrum
Repositioning side to side	Feet, heels, toes, coccyx, sacrum, occiput, scapula, spinous process, trochanter

Skin assessment

The standard of care is to conduct a routine and systematic skin assessment of all patients upon admission. Skin assessment parameters and deviations from normal are listed in Table 6-2. Examples and descriptions of lesions are presented in Chapter 5 (see Table 5-1 and Plates 6 and 7).

TABLE 6-2 Skin Assessment Parameters: Findings and Interpretation

Subsequent skin assessments should be performed routinely. Frequency of reassessment is based on baseline data, care setting, and risk for skin breakdown. For example, patients require daily skin assessments when they (1) are at increased risk for skin breakdown, (2) have impaired skin integrity, or (3) are in an acute care or long-term acute care setting.

Skin assessments require good lighting for optimal visualization. Alterations including dry skin or xerosis should be noted. Skin palpation is used to assess skin temperature and texture in all patients but is of particular importance when assessing darkly pigmented skin. Skin with deviations from normal (e.g., firm to touch, boggy, pain, itching, warmth, coolness) should be compared with the adjacent skin or contralateral body part and documented (NPUAP and EPUAP, 2009).

Darker skin tones.

Health care in the United States and Europe has experienced a shift in racial and ethnic demographics, with black and Latino/Hispanic populations being the fastest growing among patients 85 years and older (ONS 2002; Salcido, 2002). Therefore accurate assessment of patients with darker skin pigmentation is an essential skill for all health care providers, and particularly wound care providers. The unique characteristics of darker versus lighter pigmented skin are summarized in Box 3-1. Teaching points and unique considerations when assessing darkly pigmented skin are provided in Checklist 6-1 (Bennett, 1995).

CHECKLIST 6-1 Assessing Pressure Ulcers on Darkly Pigmented Skin

✓ Color remains unchanged when pressure is applied.

✓ Color changes occur at site of pressure which differ from the patient’s usual skin color.

✓ Circumscribed area of intact skin may be warm to touch. As tissue changes color, intact skin will feel cool to touch. Note gloves may diminish sensitivity to changes in skin temperature.

✓ If patient previously had a pressure ulcer, that area of skin may be lighter than original color.

✓ Localized area of skin may be purple/blue or violet (eggplant) instead of red.

✓ Localized heat (inflammation) is detected by making comparisons to surrounding skin. Localized area of warmth eventually will be replaced by area of coolness, which is a sign of tissue devitalization.

✓ Edema (nonpitting swelling) may occur with induration and may appear taut and shiny.

✓ Patient complains of discomfort at a site that is predisposed to pressure ulcer development.

Unfortunately, detection and accurate identification of erythema and Stage I pressure ulcers with standard visual inspection are unreliable in persons with darkly pigmented skin (Bates-Jensen et al, 2009; Rosen et al, 2006; WOCN Society, 2010). This inability to detect and diagnose erythema in people with highly pigmented skin is evidenced by the incongruity between the prevalence of Stage I pressure ulcers in Caucasians (48%) versus African Americans (20%) (Baumgarten et al, 2004). Another study found that 32% of pressure ulcers detected in Caucasian residents were Stage I, whereas no Stage I pressure ulcers were detected in African American residents (Rosen et al, 2006).

A handheld dermal phase meter measuring subepidermal moisture has been studied in an attempt to identify early pressure ulcer damage (Bates-Jensen et al, 2009). Findings from a descriptive cohort study of 66 nursing home residents showed that subepidermal moisture provided a more accurate method of detecting early pressure ulcer damage than did visual assessment. If these findings are supported in larger studies, subepidermal moisture may emerge to be a useful clinical technique for detecting early damage in persons with darker skin tones.

Focused physical assessment

Healing is a phenomenon composed of multiple processes (see Chapter 4), each of which must function properly and sequentially. Whereas all patients require a physical assessment, the patient with a wound requires particular attention to systemic, psychosocial, and local factors that affect wound healing. A wound specialist is specifically educated to conduct this type of focused physical assessment and to interpret the results. The focused physical assessment should be obtained upon admission and with a change of condition. Components of a wound focused physical assessment are listed in Checklist 6-2.

CHECKLIST 6-2 Physical Assessment Parameters

✓ Wound etiology and differential diagnosis

✓ Duration of wound

✓ Cofactors that impede healing:

• Comorbid conditions (malignancy; diabetes; cardiac, respiratory, renal issues)

• Medications (corticosteroids, cancer medications, immunosuppressants)

• Host infection

• Pressure ulcer risk factors

• Decreased oxygenation and tissue perfusion

• Alteration in nutrition and hydration

• Psychosocial barriers; family support; impaired access to appropriate resources, financial limitations

• Past therapies (e.g., radiation near the site of the wound)

Etiology and differential diagnosis.

Based on the wound-focused physical assessment, a differential diagnosis and likely etiology of the wound will be determined, which will drive intervention choices and treatment strategies. The completed physical assessment should help to exclude many possible etiologies for the wound but also will exclude treatment options. For example, compression is a critical intervention for successful management of the patient with venous insufficiency, but compression is contraindicated in the presence of arterial disease (see Chapter 11). Offloading is needed for management of a pressure ulcer (see Chapters 8 and 9), and glucose must be managed when the patient has diabetes (see Chapter 14). Wound etiology will also provide clues regarding the type of healing to anticipate. For example, a venous ulcer generally has little depth, so it often heals by epithelialization rather than wound contraction, which is in contrast to the deeper Stage III or IV pressure ulcer, which requires contraction for healing to occur. Measuring wound depth in the pressure ulcer clearly is an important piece of information but may be of little relevance in venous ulcers. Various types of skin damage are discussed in Chapter 5 and throughout this text. Interpretation of the data gathered through the focused physical assessment will guide the plan of care so that wound etiology and existing cofactors can be addressed.

Duration of wound and critical cofactors that impair healing.

A 4-week-old pressure ulcer that has not improved suggests the presence of cofactors that have not been adequately addressed, such as unresolved pressure, malnutrition, osteomyelitis, critical colonization, squamous cell cancer, or infection. Guidelines for pressure ulcers and arterial wounds recommend consideration of referral and biopsy for wounds that are unresponsive to 2 to 4 weeks of appropriate therapies (WOCN Society 2002, 2003).

Given a clear understanding of healing, these wounds must be considered out of synchronization and require reevaluation to identify factors that impede healing. Factors that impede healing are described in chapters throughout the text and listed in Checklist 6-2. Approaches used to assess systemic cofactors that affect wound healing along with the chapters that describe them in detail are listed in Table 6-3.

TABLE 6-3 Assessment of Cofactors

Cofactor	Diagnostic Test	Chapter
Tissue oxygenation	Transcutaneous oxygen	28
Bacterial load	Culture Biopsy	16
Circulation	Ankle–brachial index Toe–brachial index	14
Nutrition	Weight Body mass index Albumin Prealbumin Total lymphocyte count	27
Glycemic control	Blood glucose, hemoglobin A_1c	14

Wound assessment

Wound assessment is the collection of subjective data that characterize the status of the wound specifically as well as the periwound skin (see Plate 23). Parameters that compose a wound assessment are listed in Checklist 6-3 and described in this section. Conducting a wound assessment is a skill and requires precision and appropriate use of unique terms; use of appropriate terms is critically important. Therefore competency-based education for wound assessment is essential. Prior to assessment, the wound must be cleansed of loose debris, particulate matter, and dressing residue so that the normal architecture and color of the wound bed and surrounding skin can be fully appreciated.

CHECKLIST 6-3 Wound Assessment Parameters

✓ Anatomic location of wound

✓ Extent of tissue loss (i.e., stage)

✓ Characteristics of wound base

✓ Type of tissue

✓ Percentage of wound containing each type of tissue observed

✓ Dimensions of wound in cm (length, width, depth, tunneling, undermining)

✓ Exudate (amount, type)

✓ Odor

✓ Wound edges

✓ Periwound skin

✓ Presence or absence of local signs of infection

✓ Wound pain

Anatomic location.

The anatomic location of the wound is important to record using proper terminology that will also provide clues about the etiology. Anatomic locations such as the sacrum and the coccyx must be clearly delineated (Figure 6-1). The location of a wound on the plantar surface of the foot can be accurately specified by terms such as metatarsal head. Anatomic location will also convey plan of care needs. For example, a wound on the ischial tuberosity should prompt caregivers to explore the patient’s sitting surface. A typical venous ulcer commonly appears on the medial aspect of the lower leg and will require compression. A patient with diabetes and a plantar surface foot ulcer typically has neuropathy and will need adequate blood glucose control and offloading.

FIGURE 6-1 Bony structures of human body; note delineation of sacrum and coccyx.

(From Patton KT, Thibodeau GA: Anatomy and physiology, ed 7, St Louis 2010, Mosby.)

Extent of tissue involvement.

The extent of tissue damage guides the selection of appropriate interventions to restore tissue integrity; it also provides some information about the length of time required for the healing process. Extent of tissue involvement can be described as partial thickness or full thickness, or “staged” if indicated. Numerous staging and classification systems exist that are primarily based on wound etiology and therefore are precise and descriptive for that type of wound.

Partial thickness and full thickness.

A partial-thickness wound is confined to the skin layers; damage does not penetrate below the dermis and may be limited to the epidermal layers only. These wounds heal primarily by reepithelialization (see Table 4-1 and Plate 1). A full-thickness wound indicates that the epidermis and dermis have been damaged into the subcutaneous tissue or beyond; tissue loss extends below the dermis (see Table 4-2 and Plates 2–5). Wound repair will occur by neovascularization, fibroplasia, contraction, and then epithelial migration from the wound edges. Partial thickness and full thickness can be used to describe most wounds but are not precise terms for specific types of tissue loss and depths of the wound. For example, a full-thickness wound can expose subcutaneous tissue, or it may extend to bone.