Section: CME Category: Wound Care

Comprehensive Integument Assessment

Heather Hettrick, PT, PhD, CWS, CLT-LANA, CLWT

Heather Hettrick PT, PhD, CWS, CLT-LANA, CLWT discusses normal versus abnormal skin, components to perform a comprehensive skin assessment, as well as identifying unique skin characteristics for different wound etiologies.

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Goals and Objectives
  1. Recognize normal versus abnormal dermatological variants
  2. Describe the components of comprehensive skin assessment
  3. Distinguish unique skin characteristics for different wound etiologies
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  • Lecture Transcript

  • FEMALE SPEAKER: Thank you. Okay. So what I’m going to be spending the next few minutes going over with you is kind of the review of skin assessment because I think this is an area that is critically important for us all to appreciate as healthcare providers, and just understanding how we could do comprehensive skin assessment pretty quickly when we’re looking at our patients. And the importance of this is … and what I like to tell my students all the time, too, is that we need to know what’s normal for our patients so we can really readily and quickly identify what’s not normal for our patients.

    And so I’m just going to kind of take you through a little bit about a mnemonic, as Dr. McGuire was talking about, too, called dermatological, which pretty much encapsulates all the different things we should be looking for when we’re assessing our patients. So, one of the first … well, those are my disclosures. [Laughs] And I have my objectives for you, which I’m not going to read to you, but they’ll be there.

    And Pamela had mentioned, too, if any of you are interested, at the end of this presentation, for copies of this material, she’ll gladly send it to you. So we’ll just make sure we get your email address … or actually, she’ll give you her email address and then she’ll send it to you, okay? And as Gemma said, too, I agree in open-sourcing. I’m fine to share my information with you. I hope you can use it, and I hope you can show that information with other people.

    And so one of the things that I think is really important to remember is that, to really be effective at wound management, we have to really appreciate what’s going on with the skin, understanding the biology of skin, what’s normal, what’s not normal, and we have to appreciate, too, what happens as our skin ages. There’s a lot of things that are modifiable. There’s other things that are not modifiable. There are reasons we age genetically, but there’s also reasons we age environmentally. Our exposure to sun, the choices we make, whether we’re smoking or drinking, those types of activities contribute to age-related skin changes.

    We have to identify threats to the skin. We’re constantly under threat, right, from external assaults, internal assaults, and the things that we do to our patients that are iatrogenic. And then we have to really appreciate the impact that comorbidities have as well, and its impact on the skin. [00:02:03] And so a skin assessment becomes readily important.

    So this kind of a mnemonic I’ve put together to help us remember the different components we should be assessing. And it seems like a lot, but it’s actually something that we can do pretty quickly. But beyond just assessing the skin visually, we have to also feel the skin. We have to put our hands on the skin. We have to feel for tissue temperatures and integrity. We have to feel for consistency, and a bunch of other things as well. So we’re going to go through these components.

    And the first one is really just appreciating a comprehensive overview. Looking at our patients and making sure, you know … if you’re looking at them supine in the bed, we have to reposition them because we need to see the sides we can’t see when they’re laying in bed or sitting in a chair. And what we’re trying to do here is really look … is the skin intact or is it showing signs of compromise? And if so, what type of compromise? Because this is where we start to take in all that information so we can start coming up with a working clinical diagnosis of what might be the problem, whether we’re dealing with a dermatological condition, are we dealing with a wound iteology, or there is some other event that’s happening, causing problems.

    So we’re going to describe what we’re seeing. And if we can, we want to use our dermatological terms or derm terms, our primary lesions, our secondary lesions. We want to then try to classify, you know, is it presenting like a venus ulcer, orr it presenting like an arterial ulcer?

    Dr. McGuire had mentioned, too, most of these wounds are going to be of a mixed iteology. But we have to look for those unique characteristics, which we’ll go through, that can help you identify what it is you’re working with.

    And the other piece of it, too, is we have to appreciate where on the body these are showing up. Because I like to talk about wound geography and topography, because the way they present and where they’re presenting can also help us determine what type of iteology or contributing factors we’re dealing with.

    And it’s also important we look at ethnicity of the patients and pigmentation of our patients because some things are going to present a little bit differently. We’re not going to see that typical erythematous response in somebody with darker pigmented skin, but we will see dyschromia. [00:04:04] We’re going to see a darkening of their natural skin tone.

    We need to look for that because we miss that a lot, and we can miss those early indications that there might be tissue compromise. So we want to just appreciate a little bit where they are along that Fitzpatrick scale, which is used a lot in dermatology, but it’s very helpful to make sure that we are picking up situations early, because our best bet is to do prevention.

    The other thing we want to consider with respect to dermatological is R. We want to know the sensory status. So we want to – and appreciate – is the skin sensory status intact, or is it altered, and if it’s altered, how is it altered? And if there are sensory discrepancies, where are they occurring.

    We’re very familiar with neuropathy and the process of neuropathy, but we want to appreciate, specifically, what’s going on. So most of us now do light touch or we’ll do a loss of protective sensation, which we can practice later. But these are things that we need to look for, and where those discrepancies are playing in, because we know they are at significant risk for breakdown if their sensory changes.

    So the other thing we want to appreciate is soft tissue status. We’ve all had bruises and we know how much they hurt if you push on a bruise, right? But there’s areas that might look perfectly normal but there might be soft tissue problems brewing, and so are they tender touch.

    There are certain conditions. Lipedema, which is a fat disorder. These patients are very tender in those areas because the connective tissues become very fragile. So soft tissue status and appreciating how they respond to palpation can also help clue us into some of the comorbidities and underlying disease states these patients we have.

    We also want to appreciate moisture. Our skin normally is soft and supple, but sometimes it can be very dry and desiccated, and that can lead to problems like fissuring and cracking. Anytime you have a portal or an opening into the skin, you can allow a lot of bacteria to come in and it can lead to infection.

    The other thing, too, with the opposite of that, is that wet are very macerated tissues. [00:06:04] So you might have a wound that’s draining proficiently. And if we’re not managing it properly through dressing selection, those periwound areas, the periwound tissue is going to become very macerated.

    And so if you’ve ever sat in a bath tub or a pool too long and you get that wrinkling, right, the pruning of your fingers, this is essentially what maceration is. But we’ll see these in our edematous patients, particularly those with lymphedema or phlebolymphedema, where there’s so much fluid on board, it has nowhere to go but out, so those limbs literally leak. And I see some headshaking. You’ve seen these patients, right? So they may not even have an open wound per se, but their tissues are so super saturated and compromised that lymphorrhea just leaks right out unto those tissues.

    Well, that’s caustic chemical in that lymphorrhea. It’s a very caustic type of materials in there, and it can actually lead to chemical burning of the skin. So we want to appreciate how that skin moisture is presenting and where there might be deficiencies, whether it’s too dry or too moist.

    Another area that’s important to asses is that atrophic change. Those atrophic changes, those shiny, hairless legs, right? And that can be often be indicative of vascular compromise. And if you think about why, it makes sense. The adnexal structures of the skin, or your epidermal appendages, your hair follicles, your sebaceous glands, your oil glands reside in that reticular layer of the dermis, and that’s where the blood supply is fed through to provide nutrients and oxygen to the skin.

    Any time there is vascular compromise or there’s profusion problems or there’s arterial compromise, those adnexal structures are not going to be getting the oxygen and the nutrients they need, so they don’t work as well or they die off. And so if you’re having vascular changes, you’ll see it clinically and that they’re going to have that shiny hairless skin because the follicles aren’t producing hair. They’re not going to have a very good quality of sweat or even oil gland production, because again, they’re not getting adequate profusion or nutrients. [00:08:02]

    And so these are clinical science that we’ll see that are indicative or characteristic of arterial compromise, so we want to assess for that. And if somebody hasn’t had a vascular work-up in three to six months, they should be referred for another vascular work up.

    Other things we want to appreciate, too, and this is where we need to put our hands on our patients, is turgor and texture. We want to look to see for rebound, we want to feel for edematous response. We want to feel for how those tissues respond when we maybe do a pitting assessment or we’re just feeling what the quality of those tissues are like. And we’re going to go through some of this later when we do our tissue texture lab.

    So I know some of you are probably wondering why there’s fruit on your table, it’ll make sense later, all right? So we’re going to be having fun with fruit in a little while.

    So these are important things to consider, because texture and turgor are going to tell us a lot, too, about maybe what these underlying contributing factors are. Well, we understand there’s edema present, but why? And how that edema is presenting is going to tell us likely what the iteology is for that edema.

    Other things we need to appreciate, and this is critical when we’re talking about skin, is don’t forget the hair and the nails. Hair and the nails are extension of the skin, it’s just a different form of keratin. And that the quality of the hair and the nails can tell us a lot about the overall health of that skin. So if people are having problems with their hair, if people are having changes in their nails, that’s telling us, again, there may be profusion problems to the skin.

    Other things, too, with nails, and there’s a lot of good resources about clinical diagnostics. Just looking at the quality and the texture and the shape of the nails can really help us determine if there’s systemic compromise. A lot of times, patients with COPD, they’ll have clubbing of the nails, and that’s very indicative of a systemic problem. But unless you know, to look for these things, sometimes they get missed. So having … including hair and nail assessment as part of your skin assessment is important because you can pick up things that may not be really identified. [00:10:06]

    Other components, too. We want to look and feel for edema, color changes, and also temperature variations. And the edema component is really in critical … is critically important. But you have to remember, sometimes, patients, while presenting with edema, that’s sub-clinical. That means we’re not going to see it and we may not feel it, but it’s there. And that’s when these patients have early compromise with their AVL systems, those arterial, the venous and the lymphatic systems.

    And it’s really important to think of those together. Don’t separate out the arteries and the veins and the lymphatics over here, because they’re very interrelated. And when you have compromise in your venous system, you absolutely have compromise in your lymphatic system. And when you have compromise in your lymphatic system, you’re going to have compromise in your venous system. And part of that is due to the fact that your lymphatics develop out of your venous system during gestation, so they’re very intimately involved, especially with fluid hemodynamics.

    So it’s important when we’re assessing for edema is to note the location. Typically, we’re going to see it in the lower extremities, but if you have a patient with lower leg edema, you have to ask those sensitive questions, too. “Do you have edema anywhere else?” Because a lot of our patients with lymphedema of the lower legs will have genital and trunk involvement. We can manage that, but also we need to know what’s there. Okay? So you have to be comfortable asking those questions.

    And we also want to appreciate the quality of that edema. So we need to do our pitting test, and that’s when you push on that tissue, and you look to see if it leaves an indentation. There’s a lot of different scales out there that you can use to rate that edema, whether it’s a one plus, a two plus, a three plus, or a four plus. Find something that works for you and your clinical practice, and use it consistently.

    And the other thing you want to consider is rebound. Rebound is how long it takes for that tissue to come back to its normal resting state. So if you were to push on that tissue and it pits, how long does it take to come back to its normal resting state? [00:12:01] Anything greater than 30 seconds is diagnostic for lymphedema. Okay? Early on.

    Now, later, lymphedema becomes very hard and fibrotic. That’s more of the chronic cases. But early on, it’s going to take a long time for that edema to return because of the protein concentration, okay?

    The other things we need to consider are color of the skin. Is it uniform and relatively smooth throughout, or are there changes? And then, also, temperature. And again, we need to pick that up, usually through palpation. There are devices we can use to look at temperature and thermography, but we want to know, are tissues warmer or cooler than the surrounding tissues or the contralateral limbs? Because there’s things we can pick up. Maybe there’s alterations in perfusions, or there’s ischemia. Maybe there’s an underlying infection or an inflammatory response that’s going on.

    Another important thing, with respect to the foot, is to consider if there’s temperature discrepancies between the two feet. Is there an early onset of a Charcot arthropathy? So usually, anything over 5 degrees difference between the two extremities is going to be indicative of a Charcot, an impending Charcot arthropathy. So temperature is also critically important.

    The other thing, too, is to appreciate skin faults. And that includes redundant tissues in the abdomen, it can be under breast tissue between the toes.

    We really need to look for moisture lesions. A lot of these patients to present with fungal infections, yeast infections, and the like. A lot of times, too, under redundant tissue folds or under panis, or panniculi, those different – those large lobes that a lot of our patients can present, they may have pressure necrosis. There’s a lot of weight to those tissues. So sometimes they can break down just from the sheer weight of those lobules.

    We need to look for yeast and fungal infections. Yeast and fungal infect – fungus love moist areas. Well, what’s better than between the toes and under tissue folds? So not only looking, but we need to address those areas as well. So good hygiene. Drying those areas, sometimes using powders. I don’t recommend creams, but different types of antifungal powders, and the like, can be put in there to help weak that fluid away. [00:14:04] And there are some products on the market, too, that are for moisture management between folds, which can be very useful as well.

    And then we do have to look for foreign objects. You will be surprised, sometimes, what you will find. And sometimes in these tissue folds are these between the toes, especially in patients with neuropathy. So it’s critically important to look for that.

    And one extension of this is, when you’re assessing the feet with you patient, please pay attention to the shoes, not just the type of shoes that they’re coming in and wearing, but what do the shoes look like? What are the wear patterns that can tell you about pressure points. And be very mindful, don’t reach into the shoe ever. Make sure you use a pen light or a flashlight, look in the shoe, shake it out. Because sometimes, you’ll be surprised what’s actually in the shoe that can be causing disruption to the patient’s feet.

    I have found many of different substances and shoes before – in rocks and insulin needles, and coins, and you’d be surprised. So it’s very – you have to be very careful when assessing not just the feet but look at their shoes, because their shoes can tell you a lot about what’s going on in there as well.

    Other components, we need to appreciate those age-related skin changes. Unfortunately, our skin starts to age when we hit the age of 30. It starts to exponentially age when we hit the age of 65 and older. And again, these are things that we can’t always modify. So what’s important to know is what’s normal… what’s considered normal ageing skin, right?

    We’re going to see a shrinking of the dermis a little bit. We’re going to see some vascular regression. And you’re going to see the patients to be more likely to have easy bruising, some of that senile purpura. They’re more at risk for skin tears. They’re more at risk for ulceration. And this is going to be compounded sometimes too by the medications that they’re taking.

    So a lot of things can contribute to fragility of the skin and actually make the skin a little bit more potentially compromised. So we have to appreciate that and that’s important with how we handle our patients in our residence. [00:15:59] We need to be careful we’re not inducing any of those iatrogenic compromised problems for our patients because of these age-related changes.

    The other thing that’s important to remember is our skin normally works together in unison, the epidermis and the dermis because if you go back to your histology, remember those rete pegs? Those are the structures that anchor the epidermis to the dermis, so it moves as one single unit. As we get older, those rete pegs shrink in size and their integrity. And so now the epidermis and the dermis kind of don’t move as well together and they’re more subject to shear and friction. And this is why we see usually from very minor trauma, significant bruising and skin tears in our patients. And that’s not something we can modify, so we just have to be careful.

    Other components. It’s always important to inquire about allergies and past medical history because that can be contributing. And we need to find out, you know, are these things internal to the patient, are they external to the patient because sometimes they’re modifiable. And we just want to make sure we’re not making choices of products or dressings or other things to be using if they might have sensitivities to different products as well.

    Callus. Of course, we need to assess for callus. Remember, it is the body’s natural responses to repetitive stress and trauma. But it can also alter the mechanics of the foot. And so we need to address the callus, we need to pare it down, saucerize it, whatever we need to do. And then we need to offload that area as well.

    And any time you come across a hemorrhagic callus, that’s basically telling you there’s an ulcer at that base. So we need to take that callus down. And it’s one thing to take it down, but like I said, you do need to modify or accommodate to that foot so that callus doesn’t come back. So embrace your cathartics or learn ways to mitigate those risks as well.

    The last couple of things is, again, going a little bit deeper dive into the vascular status. So as Dr. McGuire said too, palpate. You know, can we feel those pulses. If not, let’s use our Dopplers. We need to look for color changes. We can do perfusion monitoring, capillary refill. [00:18:04] We can do our ankle-brachial indexes. These are really, really important because not only is it going to tell us whether it’s safe to debride, but also how much compression and the type of compressions we can be using with these patients.

    And then the last component of dermatological is really looking at whatever type of lesions may be presenting on their skin. And that can be anything, you know, so it can be a rash, it can be a wound, it can be a change in color. And we just really wanted to note anything unusual or suspicious. Because a lot of times patients present with unique dermatological variants, but that’s okay, it’s normal for that patient. But if they change and evolve, these are the ones we really want to capture early and then refer.

    So these are all the components for skin assessment. And like I said, they can be done pretty quickly. But what they lead to sometimes are the things that we’re going to be picking up clinically. And these are the characteristics we need to pay attention to. And we’re going to look at what’s common for venous, arterial and lymphatic.

    So, again, the purpose for this section is basically to appreciate the way a patient is presenting clinically can really give you very specific information to know whether you’re dealing with more of an arterial compromise, whether you’re dealing more the venous compromised or pure lymphatics. But remember, most of the time, it’s going to be a combination.

    But it’s important to pick up these things because we want to know the prevailing underlying ideology so we can manage that properly.

    So I’m going to start with this here for the sake of time. So with some of the classic changes you’re going to see with arterial is it’s going to be that pale, modeled, sometimes a cool skin, okay? And again, it makes sense when you think about it as a perfusion problem. So we’ll expect to see that. We might see even cyanosis. And you can see that sometimes in other areas as well.

    These patients classically will have a dependent rubor, so if you elevate their extremity, it gets very, very white. And then if you hang them down, it’s going to get that reperfusion, that rush to reperfuse that area. So they’re going to get that Buerger’s test with that rubor of dependency. [00:20:01]

    Thickened toe nails are not getting adequate perfusion and oxygenation, nutrition. So those toenails are going to appear normal. And also, they’ll have hair loss on the great toe for the same reason. Those hair follicles aren’t being fed properly. And they’ll have hair loss to those iatrophic changes in that lower part of the leg.

    Okay, next slide. Typical venous changes. What you’re going to see are those spider veins, those telangiectasias, the medial ankle flare where sometimes where sometimes you’ll see a lot of those spider veins at that medial ankle and foot. And varicose veins. And there are can be all sorts of different types of varicose veins that can be tortuous or distended.

    Next slide. We can see a typical atrophie blanche, which is really those ivory white patches of scar tissue with or without a wound… previous wound. And you’ll see those capillary loops. So those red dots of dilated capillary is present as well and that’s typical for venous. You’ll also see brawny skin, leathery skin, that venous rubor, that red leg, which is very classic with venous disease. And also shiny taut skin because it’s under a lot of tension from the edema.

    We’ll see lipodermatosclerosis. This is classic with venous, but also lymphedema and it’s that bounding down, that hardening of those tissues. And it can look like an inverted champagne bottle or a bowling pin.

    Classically too, sometimes we’ll see weeping, blistering of the skin, those venous stasis ulcers that typically are free of necrotic debris unless it’s a mixed presentation. We’ll also see stasis dermatitis, which is just a chronic inflammation, weepy, crusty, scale tissue. They’re very sensitive to products so we have to be careful not to use a lot of alcohol-based creams or lotions or perfumes.

    Okay, next slide. And we’ll see a lot of classically that hemosiderin staining, which is that biological tattoo. So the iron in hemoglobin leech out into the interstitial tissues, the red blood cells break down, release the iron and it stains the skin from inside out. Classic for venous disease.

    And with lymphatic changes, one of the characteristics we’re going to see here is hyperkeratosis. [00:22:00] That thickening of the skin. It can get scaly, brown, there can be grey patches of over very proliferated keratin layers. And it’s not due to poor hygiene. Sometimes it can be, but this is just a normal process we see with chronic longstanding lymphedema. It’s an over proliferation.

    We’ll see papillomatosis, that lumpy, bumpy skin or those fibrotic wart-like projections on the skin. Classic for lymphedema because of its protein-rich qualities. We’ll see that thickened fibrotic skin resembling alligator skin or even what they sometimes call like a tree bark, it’s very hard, very, very non-palpable… or not non-palpable. Non-pittable.

    And then lymphorrhea is that weeping of lymph, again, just right out on to the skin. And it chemically eats away or erodes the epidermis leading to denudement. And so this can also lead to partial thickness wounds and injuries that often are misrepresented as a venous ulceration when they’re actually itch due to a chemical burn from the lymphorrhea.

    And if you appreciate lymphatic fluid, it picks up all the gunk basically because that system is responsible for our body’s waste management system, our recycling system. We don’t want that on healthy skin. And these patients are very prone to cellulitis. It’s the leading cause of hospitalization for patients with lymphedema. And we need to pick that up early and address is early.

    And then the last thing too with lymphatics, some of the classic things would be fungal infections. We see not just between the toes but underneath some of those folds and lobules that these patients can present with because again it likes the moisture.

    What we’ve included in here are some skin assessment specific guidelines that were from the National Pressure Ulcer Advisory Panel, NPUAP or counterparts of it upon. We want you to appreciate that there are some published guidelines out there for your reference. And so we’ve included those in there for you. And as I said, Pamela would be happy to share these slides with you.

    Thank you for doing the slides for me.

    END OF CLIP
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