Skin Diagnosis – Nursing Experts Only

Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions

Photo Credit: Getty Images/iStockphoto

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare
  • Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
  • Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
  • Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
  • Consider which of the conditions is most likely to be the correct diagnosis, and why.
  • Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
  • Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
  • Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.
The Lab Assignment
  • Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
  • Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals

This interactive website allows you to explore skin conditions according to age, gender, and area of the body.  (http://www.skinsight.com/professionals)

Comprehensive SOAP Template

Patient Initials: _______ Age: _______ Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

O = onset of symptom (acute/gradual)

L= location

D= duration (recent/chronic)

C= character

A= associated symptoms/aggravating factors

R= relieving factors

T= treatments previously tried – response? Why discontinued?

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Includelast Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.

Hematologic:

Endocrine:

Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

HEENT:

Neck:

Chest/Lungs: Always include this in your PE.

Heart/Peripheral Vascular: Always include the heart in your PE.

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?

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Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions

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Comprehensive SOAP Exemplar

Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC): Coughing up phlegm and fever

History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

Medications:

1.) Lisinopril 10mg daily

2.) Combivent 2 puffs every 6 hours as needed

3.) Serovent daily

4.) Salmeterol daily

5.) Over the counter Ibuprofen 200mg -2 PO as needed

6.) Over the counter Benefiber

7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs – rash

Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet on no medication

4.) Osteopenia

5.) Allergic rhinitis

Past Surgical History (PSH):

1.) Cholecystectomy 1994

2.) Total abdominal hysterectomy (TAH) 1998

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstrating – TAH 1998

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

Significant Family History:

Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.

Lifestyle:

She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

Review of Systems:

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.

Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.

MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.

Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: no endocrine symptoms or hormone therapies.

Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

ASSESSMENT:

Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Diagnostics:

Lab:

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Differential Diagnosis (DDx):

1.) Acute Bronchitis

2.) Pulmonary Embolis

3.) Lung Cancer

Diagnoses/Client Problems:

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40 pack year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet on no current medication

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

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Key Points

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Ball: Seidel’s Guide to Physical Examination, 8th EditionChapter 08 : Skin, Hair, and NailsKey PointsThis review discusses examination of the skin, hair, and nails.Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass or dermatoscope; and Wood’s lamp.To examine the skin, perform the following.Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.Inspect the skin in two ways.First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences among body areas, and compare sun-exposed areas with areas that were not exposed to the sun.Second, observe the skin as each part of the body is examined.When evaluating the skin and mucous membranes in each part of the body, note six characteristics.The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is at areas of pressure or rubbing, such as the elbows, soles, and palms.The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.The fifth characteristic is hygiene, which may contribute to skin condition.The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.During inspection, also palpate the skin to determine five characteristics.First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm but should be bilaterally symmetrical.Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined.First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.If the lesion has exudates, note their color, odor, amount, and consistency.If there is more than one lesion, describe their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.Record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.Use a light and magnifying glass to determine the lesion’s subtle details, including color, elevation, and borders.To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection.To examine the hair, perform the following.To assess the hair, palpate its texture. Scalp hair may be coarse or fine and curly or straight. It should be shiny, smooth, and resilient.During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.Hair color ranges from very light blond to black to gray.Hair distribution and quantity vary with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.To examine the nails, perform the following.Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.Inspect the nails for six characteristics: color, length, condition, configuration, symmetry, and cleanliness.Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.The nails should appear bilaterally symmetrical.The nails should be clean, smooth, and neat.Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.The nail-base angle should measure 160 degrees.If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.The texture of the nail plate should be hard and smooth.The nail base should be firm—not boggy.The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad.

8-2

Student Checklist

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Ball: Seidel’s Guide to Physical Examination, 8th EditionChapter 0 8: Skin, Hair, and NailsStudent ChecklistAssessed Appropriately by Student?YesNoCommentsI. Inspection and palpation of the skinA. ColorB. UniformityC. ThicknessD. SymmetryE. HygieneF. Lesions1. Primary2. Secondary3. Size4. Shape5. Color6. Texture7. Elevation or depression8. Attachment at base9. Exudates10. Configuration11. Location and distributionG. OdorsH. MoistureI. TemperatureJ. TextureK. TurgorL. MobilityII. Inspection and palpation of the hairA. ColorB. DistributionC. QuantityD. TextureIII. Inspection and palpation of the nailsA. Pigmentation, length, symmetry, and ridging or irregularities (redness, swelling, pain, exudate, warts, cysts, or tumors)B. Measure nail base angleC. Texture, firmness, thickness, uniformity, and adherence to nail bed

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Assessing and managing skin tears in older people

Annie Clothier

Abstract The skin is the largest and most visible organ in the body, comprising of two principal layers, the dermis and epidermis (Timmons, 2006). Skin tears are acute, traumatic injuries, presenting predominantly in the extremities of the elderly, as a result of friction and shearing forces which separate the principal layers of the skin (Baranoski, 2005). Skin tears cause significant pain and adversely affect quality of life. It is essential that health professionals ensure they are confident and competent in the management of skin tears. This article discusses how to assess and manage skin tears in older people and provides an overview of factors to consider when choosing an appropriate dressing.

Annie Clothier is a tissue viability nurse, at Aneurin Bevan University Health Board, South Wales

Skin tears are acute, traumatic injuries, presenting predominantly in the elderly. They occur mainly on the extremities as a result of friction and shearing forces which separate the principal layers of the skin (Baranoski, 2005).

Skin tears were first defined in 1993 (Payne and Martin, 1993). Some are unavoidable, but many are considered preventable (Payne and Martin, 1993; Leblanc et al, 2013). Although they are perceived to be common among the elderly, these types of wounds often go unreported, especially in the community setting (Stephen-Haynes and Carville, 2011).

The majority of prevalence and incidence data originate from the USA and Australia. To date, there is no robust prevalence data available for the UK. Therefore the financial impact of skin tears on the NHS is not fully known (Bianchi, 2012).

The main causes of skin tears are mechanical trauma, often from wheelchair injuries, removal of adhesive tapes or dressings, transfers and falls (Baranoski, 2005; Battersby, 2009; Beldon, 2006; Groom et al, 2010), though in some cases no apparent cause is found (Baranoski, 2005).

In older people, most skin tears are seen on the extremities, usually the arms, dorsal aspect of the hands, and the lower limbs.

Skin tears cause significant pain and adversely affect quality of life. With an ageing population, it is essential that health professionals ensure they are confident and competent in the management of skin tears.

Physiology of ageing skin The skin is the largest and most visible organ in the body, comprising of two principal layers, the dermis and epidermis (Timmons, 2006).

As the skin ages, the amount of elastin and collagen reduces, resulting in visible changes, such as sagging and wrinkling, along with dryness, which is a result of lower levels of the dermal proteins which retain moisture (Battersby, 2009; Nazarko, 2007; Fleck, 2007).

The epidermis thins over time, leaving it more susceptible to mechanical trauma (Baranoski, 2005). Given the ‘tissue paper’ appearance of the skin, even the slightest bump or knock can cause tissue damage (Stephen-Haynes and Carville, 2011; Fleck, 2007).

Maintaining skin integrity can pose a challenge for health professionals working with older people. The occurrence of skin tears may reflect poorly on the quality of care provided by care homes and other healthcare facilities, so collecting data is considered essential to understand the magnitude of the problem (Leblanc and Baranoski, 2011).

Assessment and classification Assessment must follow a comprehensive and holistic approach. Underlying factors which may have contributed to the injury should be determined (Battersby, 2009). Conditions such as diabetes, anaemia or postural hypotension need to be addressed to prevent further tears occurring (Beldon, 2008).

A common sense approach to patient care should focus on addressing the risk factors associated with the development of a skin tear (Box 1), and modifying risks, for example by employing safer manual handling techniques, while assisting older adults with routine activities such as bathing, dressing and repositioning (Payne and Martin, 1993).

Creating a safe environment is essential to avoid unnecessary trauma from any bumps or knocks from

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Tissue Viability Nurse Forum, 2011; Carville et al, 2007).

The clinician must thoroughly assess the wound to determine the extent and depth of the damage (Battersby, 2009).

When assessing a skin tear, it is important to document the position of the skin tear; pain levels; size of the tear; description of the wound bed; level and appearance of exudate; and the integrity of the surrounding skin.

The All Wales Tissue Viability Forum recommends that assessment of the skin tear should include (All Wales Tissue Viability Nurse Forum, 2011):

■ Underlying disease process (e.g. diabetes, peripheral vascular disease)

■ Cause of the injury ■ Time of the injury ■ Previous skin injury ■ Status of surrounding skin ■ Nutritional status ■ Medication ■ Wound location ■ Size and category of the wound. There is no universally accepted classification for the

assessment of skin tears (Stephen-Haynes and Carville, 2011; Battersby, 2009; Leblanc and Baranoski, 2011; All Wales Tissue Viability Nurse Forum, 2011). The most widely documented is the Payne and Martin tool (Payne and Martin, 1993) (Box 2).

In recent years however, the formation of the International Skin Tear Advisory Panel (ISTAP) has initiated consensus statements and further work towards an internationally recognised and validated classification system (Payne and Martin, 1993). The ISTAP system is concise in that it focuses on three types of skin tear (Groom et al, 2010).

■ Type 1: Linear or flap tear that can be repositioned to cover the wound bed

■ Type 2: Partial flap loss that cannot be repositioned to cover that wound bed

■ Type 3: Total flap loss exposing the entire wound bed. In 2007, Carville et al published the STAR

classification system (Box 3) and it is interesting to note that in recent years it has been disseminated outside of Australia (Leblanc and Baranoski, 2011; Carville et al, 2007).

Managing skin tears The main aim of managing a skin tear is preserving the skin flap and protecting the surrounding tissue (Stephen-Haynes and Carville, 2011). As with any wound, the focus is on encouraging healing and preventing infection.

The All Wales Tissue Viability Forum Best Practice Statement is a useful tool for any practitioner and gives clear guidelines for assessing and managing skin tears

low lying furniture. Nurses can advise on the padding of sharp corners on furniture. Patients can be encouraged to wear some degree of protective clothing such as long sleeves and trousers in an attempt to cover the vulnerable areas (Payne and Martin, 1993; Leblanc et al, 2013; Fleck, 2007).

Care should also be taken when removing tapes and adhesive dressings. Gently grasping one edge and slowly peeling the dressing back, rather than up, in the direction of the hair growth will help reduce the trauma of removing adhesive dressings and tapes that are difficult to remove (All Wales Tissue Viability Nurse Forum, 2011). The use of a barrier film or cream can help to moisturize and protect the skin, and using a silicone-based adhesive remover for dressings will minimize trauma to fragile skin (Leblanc et al, 2013).

The importance of keeping the skin hydrated has been recognized and the use of topical emollients advocated, in conjunction with ensuring an adequate oral fluid intake (Fleck, 2007). This can be the difference between a bump resulting in a bruise or a skin tear (Fleck, 2007). There are many skin care products available that provide pH-balanced cleansing which further reduces drying effects on the skin (Payne and Martin, 1993).

It is essential that the cause of a skin tear is established to enable effective care planning that takes into account the risk factors involved (Stephen- Haynes and Carville, 2011; Fleck, 2007; All Wales

Box 1. Risk factors for skin tears ■ Age >75 years ■ Gender (more common in females) ■ History of previous skin tears ■ Dehydrated skin ■ Impaired mobility ■ Reliance on others for personal needs such as bathing or transferring

■ Cognitive or sensory impairment (diabetes, dementia) ■ Visual impairment ■ Poor nutrition and hydration ■ Medications that can have a thinning effect on the skin (e.g. steroids).

Box 2. Payne and Martin classification ■ Category 1: A skin tear without loss of tissue, either linear or with a flap that closes the tear to within 1 mm of the wound edges

■ Category 2: Partial tissue loss, scant when tissue loss is <25%. Moderate or large when the tissue loss is >25%

■ Category 3: Complete tissue loss with no epidermal flap covering the injury.

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(All Wales Tissue Viability Nurse Forum, 2011). It is freely available to download.

With any skin tear, it is essential that treatment is prompt in order to ensure the viability of the skin flap. The initial treatment process includes (Stephen-Haynes and Carville, 2011; Battersby, 2009; All Wales Tissue Viability Nurse Forum, 2011):

■ Control bleeding—apply pressure and elevate the limb

■ Cleanse the wound—use warm tap water or saline to irrigate and remove any debris or remaining clots

■ Approximate the flap—without pulling or applying pressure, gently unfold the flap and smooth it out over the wound. This can be done using a moistened, gloved finger or cotton tip

■ Dress the wound with an atraumatic wound contact layer to keep the flap in place. The atraumatic dressing should remain in place for several days to allow the flap to adhere to the wound bed. Ensure that the atraumatic layer is removed in the direction of the skin flap, and not against it

■ Sutures and staples are not recommended due to the fragile nature of the tissue

■ The wound should be monitored regularly for signs of infection (redness, heat, odour and increased pain and exudate). Particular care should be taken in the immunocompromised and people with diabetes

■ If the skin flap becomes necrotic, a specialist opinion should be sought from a tissue viability nurse or medical practitioner.

Choosing a dressing Dressing selection is important, but due to limited knowledge among some practitioners, inappropriate choices can be made. The ideal dressing should (Stephen-Haynes and Carville, 2011; Leblanc and Baranoski, 2011):

■ Maintain a moist environment (Stephen-Haynes and Carville, 2011; Battersby, 2009; Leblanc and Baranoski, 2011; All Wales Tissue Viability Nurse Forum, 2011; Carville et al, 2007)

■ Protect the surrounding skin ■ Control and manage exudate levels ■ Prevent trauma on removal ■ Give the patient comfort and security and optimize their well-being

■ Be easy to apply and cost effective. The All Wales Tissue Viability Forum advocates

the use of an atraumatic contact layer such as Silflex (Advancis Medical) or Mepitel (Molnlycke), or an atraumatic all in one dressing like Mepilex Border (Molnlycke) or Allevyn Gentle Border (Smith and Nephew) (All Wales Tissue Viability Nurse Forum, 2011). If using an all-in-one dressing, then it is advisable to mark the dressing with an arrow to

indicate the direction in which the dressing is to be removed.

In some cases, the patient may need to be referred to secondary care for further treatment and possible plastic surgery. This is particularly important if there has been full thickness tissue loss or a haematoma has formed.

Preventing skin tears As with all things, prevention is better than cure. The ISTAP guidelines specify that care needs to be planned and that a comprehensive assessment of the risk factors for skin tears must be conducted for all individuals at risk within the context of their environment (Leblanc and Baranoski, 2011).

The need to ensure that care giving staff are aware of proper handling techniques required for providing care without traumatizing the skin in vulnerable older adults is essential and should form part of an annual educational review.

Involvement of the multidisciplinary team should be considered to advise on a number of factors such as safer handling equipment that minimizes trauma to the skin, and consulting a dietician for advice on maintaining an adequate nutritional and hydration level. Most importantly, the individual patient and their family should be involved in deciding on and adopting prevention strategies (Leblanc and Baranoski, 2011).

Conclusion Skin tears present a challenge for the health practitioner. Care home establishments have a duty to ensure staff are educated in managing the skin of older adults.

Registered nurses should be aware of the risk factors for skin tears (Box 1) and, where possible, work to eliminate these. Environmental factors can

Box 3. STAR classification ■ Category 1a: A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened

■ Category 1b: A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened

■ Category 2a: A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened

■ Category 2b: A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened

■ Category 3: A skin tear where the skin or flap is completely absent.

(Baranoski, 2005)

Clinical Focus

282� Nurse Prescribing�2014�Vol�12�No�6

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be implicated in the aetiology of skin tears. However, education and the enforcement of protocols for managing skin care can result in a reduction in the occurrence of skin tears (Baranoski, 2005).

A better understanding of the classification and treatment required will enable nurses to feel confident and aid decision-making, improving and enhancing the outcomes for the patient.

This article was originally published in Independent Nurse, 5 May 2014.

All Wales Tissue Viability Nurse Forum (2011) Best Practice Statement. The Assessment and Management of Skin Tears. MA Healthcare: Dulwich; 2011. Available from: http://bit. ly/1pnYA1q.

Baranoski S (2005) Meeting the challenge of skin tears. Adv Skin Wound Care 18: 74–5

Battersby L (2009) Exploring best practice in the management of skin tears in older people. Nurs Times 105: 22–6

Beldon P (2006) Best practice for the assessment and management of superficial skin tears. Wound Essentials 1: 108–9

Beldon P (2008) Management options for patients with pretibial lacerations. Nurs Standard 22: 53–8

Bianchi J (2012) Preventing, assessing and managing skin tears. Nurs Times 108: 12–6

Carville K, Lewin G, Newall N et al (2007) STAR: a consensus for skin tear classification. Primary Intention 15: 18–28

Fleck C (2007) Preventing and treating skin tears. Adv Skin Wound Care 20: 315–20

Groom M, Shannon RJ, Chakravarthy D, Fleck CA (2010) An evaluation of costs and effects of a nutrient-based skin care program as a component of prevention of skin tears in an extended convalescent center. J Wound Ostomy Continence Nurse 37: 46–51. doi: 10.1097/WON.0b013e3181c68c89.

Leblanc K, Baranoski S, Holloway S, Langemo D (2013) Validation of a new Classification system for Skin Tears. Adv Skin Wound Care 26: 263–5. doi: 10.1097/01.ASW.0000430393.04763.c7.

Leblanc K, Baranoski S (2011) Skin tears: state of the science: consensus statements for the prevention, prediction, assessment and treatment of skin tears. Adv Skin Wound Care 24(9 Suppl 1): 2–15. Available from: http://bit.ly/1gOJGrO.

Nazarko L (2007) Maintaining the condition of aging skin. Nursing and Residential Care 9: 160–3

Payne RL, Martin ML (1993) Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 39: 16–22

Stephen-Haynes J, Carville K (2011) Skin tears Made Easy. Wounds International 2(4): 1–6

Timmons J (2006) Skin function and healing. Wound Essentials 1: 8–17

Key Points ■ Skin tears are acute, traumatic injuries, presenting predominantly in the elderly—the majority are thought to be preventable

■ Care should be taken when removing adhesive dressings and tapes

■ It is important to keep the skin hydrated, and topical emollients have been advocated, along with ensuring an adequate fluid intake

■ The main aim of managing a skin tear is preserving the skin flap and protecting the surrounding tissue

■ Dressings should maintain a moist environment, protect the surrounding skin, control and manage exudate levels, and prevent trauma on removal.

Copyright of Nurse Prescribing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.

8-2

Key Points

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Ball: Seidel’s Guide to Physical Examination, 8th EditionChapter 08 : Skin, Hair, and NailsKey PointsThis review discusses examination of the skin, hair, and nails.Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass or dermatoscope; and Wood’s lamp.To examine the skin, perform the following.Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.Inspect the skin in two ways.First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences among body areas, and compare sun-exposed areas with areas that were not exposed to the sun.Second, observe the skin as each part of the body is examined.When evaluating the skin and mucous membranes in each part of the body, note six characteristics.The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is at areas of pressure or rubbing, such as the elbows, soles, and palms.The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.The fifth characteristic is hygiene, which may contribute to skin condition.The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.During inspection, also palpate the skin to determine five characteristics.First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm but should be bilaterally symmetrical.Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined.First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.If the lesion has exudates, note their color, odor, amount, and consistency.If there is more than one lesion, describe their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.Record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.Use a light and magnifying glass to determine the lesion’s subtle details, including color, elevation, and borders.To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection.To examine the hair, perform the following.To assess the hair, palpate its texture. Scalp hair may be coarse or fine and curly or straight. It should be shiny, smooth, and resilient.During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.Hair color ranges from very light blond to black to gray.Hair distribution and quantity vary with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.To examine the nails, perform the following.Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.Inspect the nails for six characteristics: color, length, condition, configuration, symmetry, and cleanliness.Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.The nails should appear bilaterally symmetrical.The nails should be clean, smooth, and neat.Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.The nail-base angle should measure 160 degrees.If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.The texture of the nail plate should be hard and smooth.The nail base should be firm—not boggy.The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad.

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