TIP OF THE WEEK
Detecting skin changes on residents
To accurately detect skin changes, visual assessment must be followed by a thorough physical assessment of the wound and its surrounding skin. The skin surrounding a wound can provide the assessing clinician with valuable information regarding ongoing evaluations and future wound care management (Baranoski and Ayello 2004). Asking residents and/or caregivers about skin changes can also prove useful.
Failure to observe the above may increase the risk of a resident developing a pressure ulcer or wound infection. Considering the following conditions when performing a physical skin or wound assessment.
INFLAMMATION
Inflammation is a normal physiological response to tissue insult or injury and is integral to microbial resistance (Gardner and Frantz 2004). In surgical wounds, inflammation occurs following an incision and wounding, but should subside within five days post-operatively (Stotts 1998). The inflammatory process is triggered by endogenous (host sources) and exogenous (microbial) mediators. The release of inflammatory mediators results in localized vasodilation and increased blood flow to the injured area. These chemical mediators are key to the inflammatory process. The accompanying increase in vascular permeability promotes a rapid influx of phagocytic cells and antibodies to the wound site. Collectively, these events cause the removal of microorganisms, debris and bacterial toxins and enzymes. These physiological responses to injury are demonstrated by the signs of inflammation including erythema, heat, edema, and pain (Gardner and Frantz 2004).
Inflammation is either acute or chronic. Acute inflammation is the initial response to tissue invasion or injury. Chronic inflammation occurs if the invasion or injury of tissue is not resolved and persists over a long period (Gardner and Frantz 2004).
ERYTHEMA
The change in usual skin color results from the dilation of capillaries near the skin’s surface, which is mediated by polymorphonuclear leukocytes, monocytes, and macrophages. For surgical-related wounds, this phase usually occurs from the time of initial insult to about two to five days’ post-injury.
Color is a proven indicator of a physiological response to injury and a good indicator of a stage 1 pressure ulcer (Lyder 1991). In residents with darkly pigmented skin, erythema is difficult to detect (Bennett 1995). In lightly pigmented skin the presence of erythema is detected by bright or dark red skin, and by darkening in residents with darkly pigmented skin (Gardner and Frantz 2004).
Most clinicians agree that color and temperature play a major role in the identification and assessment of stage one pressure ulcers (Agency for Health Care Policy and Research 1992, Parish et al 1997, EPUAP 1999), and almost all pressure ulcer classifications include erythema as a category (Lyder 1991). However, erythema is not only difficult to detect in darkly pigmented skin, but it is also characteristic of many skin conditions other than pressure ulcers, including allergic reactions and excoriation from fecal incontinence caused by alkaline enzymes in the stool which irritate the skin (Alterescu and Alterescu 1988).
Lyder (2005) suggests using a penlight to observe changes in skin color. However, this is a subjective assessment (Matas et al 2001). Lyder et al. (1998) report that caregivers who are not of the same ethnic background as residents may be less sensitive to slight changes in skin color. This is an important factor to consider in the assessment of residents with darkly pigmented skin (Lyder 1991).
TEMPERATURE
Skin is usually warm to touch. If it is warmer than usual this could be a sign of inflammation, and an indicator of infection or pressure damage.
Increased local blood flow and edema are followed by engorgement of surrounding vessels and tissues resulting in warmth and redness in the area. Pale and cool skin may be a sign of poor perfusion or ischemia and may indicate the end stage of non-blanching erythema (Lyder 1991, NPUAP 1998), usually caused by cell damage and activation of hemostatic mechanisms (Barton and Barton 1981).
An increase or decrease in skin temperature is usually detectable by touch (Parish et al. 1988, Bliss 2000). Flanagan (1996) states that these temperature changes are slight and detection can be made easier by avoiding the use of gloves. However, Lyder (2005) challenges this and argues that in clinical practice a rise in temperature of 1-2 degrees is difficult to assess with or without gloves; practitioners’ fingers are not usually that sensitive. However, this assessment is important in residents with darkly pigmented skin because of the difficulty in observing color changes.
EDEMA
Edema is one of the physiological signs of inflammation, and is also indicative of heart, liver, and kidney failure, as well as venous insufficiency. In the case of suspected pressure ulceration, wound infection, or abscess formation, edema can be palpated in areas of suspected damage, irrespective of skin pigmentation.
Gardner and Frantz (2004) state that shiny, taut skin or pitting impressions in the skin adjacent to any wound but within 4 cm. of the wound margin indicate edema. This can be assessed by pressing firmly within 4 cm. of the ulcer margin with a finger, releasing and waiting five seconds to observe for any indentation (Gardner and Frantz 2004). Edema and induration occur because pressure causes separation in the skin layers and allows interstitial fluid to accumulate (Longe 1986). Therefore, both edema and induration are good indicators of tissue damage. Parish et al. (1988) found that at this stage there is engorgement of capillaries and venules in the papillary dermis.
TURGOR
Skin should quickly return to its original state when it is assessed and palpated. A slow return may indicate dehydration or the effects of aging. Soft tissue may indicate an underlying infection. Tense skin may indicate lymphedema and cellulitis. Palpation is useful to assess skin temperature, edema and turgor of suspected damaged areas.
MOISTURE
It is important to note whether skin is moist or dry during assessment. If it is dry, look for hyperkeratosis (flaking and scales). Observe for eczema or dermatitis, psoriasis rashes, leaking edema, or exudate. These signs may aid diagnosis in residents with cellulitis, lymphedema or wet gangrene.
No consensus as to what constitutes a minimal skin assessment exists in the literature (Baranoski and Ayello 2004). A skin assessment differs from a wound assessment as it should include observation of the resident’s entire body, not only areas with wounds. Lesions, bruising, absence of hair, shiny skin, callus formation, scars (hypertrophic and keloid scars are more prevalent in residents with darkly pigmented skin (Placik and Lewis 1992)) and signs of venous insufficiency such as hemosiderin deposits (reddish-brown color), ankle flare and atrophy blanche can be identified. Hemosiderin deposits are often seen on the lower legs of residents with venous ulcers and lightly pigmented skin. However, in residents with darkly pigmented skin the signs of venous insufficiency are difficult to detect and resident history becomes the key to aid diagnosis. Arterial ulcers often present with the classic signs of hair loss, weak or absent pulses, and thin, shiny, taut skin.
Residents with diabetes are prone to callus formations. All of these diagnostic features can be detected during an assessment (Baranoski and Ayello 2004).
Physical examination and resident history should reveal why the resident has a wound and, if it is not healing, why healing is not taking place irrespective of age, race or skin color. This should be documented in the plan of care.
RESOURCE SPOTLIGHT
Ohio KePRO Pressure Ulcer Resource CD-ROM
This CD-ROM includes an entire manual of information designed to help you improve in the pressure ulcer quality measure. Items include screening tools, assessment checklists, and other resources.
To order, click here and select “Nursing Home” in the drop-down box. Then, scroll to the bottom and add the Workforce Retention Resource CD-ROM to your cart. Finally, proceed to checkout. All resources in the Ohio KePRO Shopping Bag are free of charge to Ohio healthcare providers. Please allow 10 business days to process your request.
IN THE NEWS
March 22, 2007 -- PR Newswire -- Managing Transitions to Care for the Frail Elderly, an April 26, 2007 audio conference, will explore how to create effective care management approaches for the frail elderly. Read more >>
PROBLEMS WITH PATIENT COMMUNICATION INCREASE RISK FOR INJURY, DEATH
March 26, 2007 -- Kaiser Network -- Problems with communication between patients and health care providers can increase risk for injury or death for those who require medical care, according to a report recently released by the Joint Commission, USA Today reports. The report found that cultural and language barriers, as well as low literacy skills among patients, can affect communication between patients and providers. Read more >>
NURSING HOMES SEEKING MORE SHORT-TERM, LUCRATIVE REHAB PATIENTS
March 27, 2007 -- Kaiser Network -- The AP/Atlanta Journal-Constitution examined how, with "billions of dollars at stake, nursing homes across the nation are rushing to reinvent themselves to compete with hospitals and affiliated rehabilitation facilities for short-term, higher-paying patients." The nursing home industry for decades has focused on older, sicker patients. Read more >>
NURSING HOMES WANT STATE TO PAY WORKERS' COMP HIKE
March 28, 2007 -- Zanesville Times Recorder -- A trade group representing Ohio nursing homes is asking the Ohio Supreme Court to decide who should pay for increases in premiums to the state's injured-worker insurance program.
Lower courts have ruled in the state's favor, ordering nursing homes to pay the additional amount. The nursing homes are asking that the state cover payments for increases that occurred when the Ohio Bureau of Workers' Compensation ended a discount for businesses.
Read more >>
OHIO KEPRO EVENTS
COMMUNITY OF PRACTICE CONFERENCE CALLS
Choose one or more topics of interests and dial in to discuss best practices and barriers to improvement with your peers in the nursing home industry. These calls are designed for interactive discussion; come prepared to discuss your successes and barriers.
Dial-In: 1-800-895-1715
Conference ID: COP
Topic |
Call One |
Call Two |
Pressure Ulcers |
3/13/07, 10AM or 3/15/07, 2PM |
4/17/07, 10AM or 4/19/07, 2PM |
Pain |
3/27/07, 10AM or 3/29/07, 2PM |
4/24/07, 10AM or 4/26/07, 2PM |
Restraints |
4/3/07, 10AM or 4/5/07, 2PM |
5/1/07, 10AM or 5/3/07, 2PM |
For more information, please contact the Nursing Home Team at 1-800-385-5080
View all Ohio KePRO educational opportunities for nursing homes >>
INDUSTRY EVENTS
PRESSURE ULCERS: THE POWER OF PREVENTION AND EARLY DETECTION
A workshop series presented by American Medical Technologies in support of the Advancing Excellence in America’s Nursing Homes Campaign. April 18-26, 2007 in locations throughout Ohio. Registration one week in advance is required. Register now
2007 DQA QUALITY FORUMS FOR NURSING HOMES
In April and May, the Ohio Division of Quality Assurance (DQA) is presenting one-half day quality forums to discuss current issues with Nursing Home Administrators, Directors of Nursing and Maintenance Supervisors (limited to two participants per facility, advanced registration is required). The quality forums will include the following topics: GPRA goals/restraint use guidelines, MRSA in LTC, LTC updates, enforcement updates, and life safety code updates.
Dementia: The Emerging Epidemic, A support group meeting for family, friends, and caregivers
May 10, 2007, 7:00pm to 8:30pm, Courtyard by Marriott, Springfield, OH.
Call OMH, Rita Brown at 937-525-3000 to register before May 3, 2007.
Navigating the MDS Through the Ohio Medicaid Reimbursement System
Ohio Department of Job and Family Services
June 11, 2007 or August 23, 2007
Call Cheryl Robertson at (614) 466-9088 for more information.
Upcoming CMS Webcasts
Advancing Excellence in Nursing Homes
April 23, 2007, 1:00 p.m.
From Institutional to Individual Care Part III: Clinical Case Studies in Culture Change
April 27, 2007, 1:00 p.m.
Medicare Learning Network: Learning resources and products for the healthcare professional.
Alzheimer’s Association Training Events
Case Western Reserve University School of Medicine Courses
Ohio Department of Health, Technical Assistance Program – New Programs
Ohio Health Care Association Events
An archive of The Nursing Home Weekly Update is available on our Web site. Click here >>
