Caregivers need to know what to look for while assessing a resident’s skin in order to deliver high-quality care and detect potential threats.

W

hether you have been in healthcare for six months or 10 years, you are bound to have come across a patient with an alteration in the skin for which you thought, “What is that?” Even for experienced clinicians, there are times when we have to mentally run though the known definitions to try and determine the etiology of a particular lesion—and do it quickly so the patients do not wonder what we are mumbling about as we examine their skin.
       The purpose of this article is to review some of the more common— and a few of the not so common—skin alterations. Nurses and nurse assistants are often the first and most frequent healthcare providers to do a careful

Table 1

head-to-toe assessment of the patient’s skin. So it is important to be able to evaluate what we see for assessment and treatment purposes as well as alerting the physician to these conditions.
       Another reason it is essential to be able to determine the cause of a skin lesion is the potential for negative consequences associated with some ulcers. Pressure ulcers have long been considered a nursing quality-of-care indicator. The Joint Commission’s 2006 Patient Safety Goals for long-term care and the “Guidance for Long Term Care” published by the Centers for Medicare & Medicaid Services (CMS) highlight the importance preventing healthcare-associated pressure ulcers.^1-3 Inaccurately identifying other chronic ulcers as pressure ulcers can cause an unwarranted cascade of financial and reputation-related consequences.

Causes: Pressure

       Accurately determining the cause of a skin lesion begins with a thorough patient history and assessment. The importance of reviewing medical records from the previous healthcare facility

Figure 1

(if available) cannot be overstated. For example, Ms. J is an 84-year-old female admitted for rehabilitation after a left hip fracture sustained when she fell at home. The fracture was repaired at the local acute care facility. She has a diagnosis of diabetes mellitus type 2, coronary artery disease (CAD), Parkinson’s disease, and peripheral vascular disease (PVD). Upon admission, a lesion (see Figure 1) is noted on her left heel.
       You determine that, given the characteristics of the wound (intact blister) and the location (left heel—same side as the hip fracture), this lesion is a pressure ulcer. Using the National Pressure Ulcer Advisory Panel’s (NPUAP)

Figure 2

Pressure Ulcer Staging System (see Table 1), you determine that the ulcer is a stage 2.

Causes: Vascular Insufficiency

       Let us get back to Ms. J. Now, given the same patient with the same history, what would you determine is the most likely cause of this wound on her right lower medial calf (see Figure 7)? Since the ulcer is not on a

Figure 3

bony prominence and does not appear to be in the shape of a medical device, you decide that it is not a pressure ulcer. You note the absence of pedal and posterior tibial pulses on the right foot and that the foot is cooler to touch than the left. She does not have lower extremity edema. What is this lesion? The most likely etiology of this ulcer is vascular insufficiency—probably arterial, given the diagnoses of diabetes mellitus, CAD, and PVD; the absence of pulses; and the temperature of the foot. (See Table 2 to compare and contrast venous and arterial ulcers.) It is proper to conduct further testing (eg, ankle-brachial index [ABI], noninvasive

Figure 4

flow studies, magnetic resonance angiography [MRA]), but you can confidently rule out pressure as the primary cause.

Causes: Dermatologic Manifestations

       Ms. J developed a urinary tract infection (UTI) and has been on an antibiotic therapy for two weeks. She has been progressing very slowly with rehabilitation services, spending most of her time in the bed o

Figure 5

r bedside chair. Her urinary catheter was discontinued when she developed the UTI, and she has since been incontinent of urine. During morning care, the certified nursing assistant (CNA) calls you to the room to see this lesion (see Figure 8).
       Perineal dermatitis or incontinence-associated dermatitis refers to the skin from groin to buttock that is irritated and/or inflamed due to contact with a caustic substance.⁴ In Ms., J’s case, the urine caused an overhydration

Figure 6

and maceration of the skin that allowed the pH and urea to penetrate the first layer of her skin and cause damage (see Table 3 for a perineal dermatitis algorithm). Since she is spending so much time in the bed or chair and she is on an antibiotic that can decrease her normal bacterial flora, her perineal area becomes a warm, moist, and dark place that is ideal for a fungus to grow. If not treated effectively, she is at even higher risk for pressure ulcer development.

Figure 7

       Returning to Ms. J, three days later the CNA calls you back into her room. Ms. J has developed

Table 2

diarrhea, and a stool culture is now pending. Unfortunately, the bowel movements are uncontrollable, and she is frequently incontinent. Her buttock has a skin lesion (see Figure 9).

Figure 8

       Ms. J has progressed along the perineal dermatitis algorithm to now have erosions on the skin related to not only urine but stool and friction. Since she needs assistance moving in bed, the friction from the bed linens has easily caused open erosions in fragile, damaged skin. You note that the lesions are not located on the bony prominence or in the shape of a medical device. Therefore, you correctly conclude that they are not pressure ulcers but incontinence

Figure 9

erosions consistent with severe perineal dermatitis.
       We now turn our attention to Mrs. H. She is on hospice for a diagnosis of end-stage lung cancer. She has a urinary catheter in place and is incontinent of formed stools daily. She is dependent for all activities of daily living (ADLs), including bed mobility. The CNA pages you to Mrs. H’s bedside to see lesions (see Figure 10) in her left buttock.

Figure 10

       Since the lesions are not on a bony prominence or in the shape of a medical device, you know they are not pressure ulcers. While she is incontinent of stool, the lesions are isolated without a red and peeling rash that would be more typical for perineal dermatitis. Recognizing that Mrs. H is likely immunocompromised due to her terminal illness, you consider other possible skin lesions. Grouped vesicles in an immunocompromised host would raise suspicion for a viral etiology. Herpes simplex is a common offending agent, and it involves very painful skin lesions.

Figure 11

       When a patient is bedridden, it is not uncommon to miss the vesicles associated with herpetic lesions because of the frequent friction and trauma to the area that will un-roof them. As herpetic lesions progress, they will typically have a punched-out appearance. When several lesions coalesce, the resulting lesion will have a scalloped edge (see Figure 11) and can easily be confused with pressure damage. The patient or resident may also report of severe pain that is often described as “burning.”

Causes: Diabetic/Neuropathic

       Mr. P has been admitted to your unit with a foot ulcer and

Figure 12

uncontrolled diabetes mellitus. He was ambulatory prior to admission, so you are thinking that the lesion might not be a pressure ulcer. When he takes off his sock, you find an ulcer (see Figure 12). The ring of hyperkeratotic tissue around the wound gives an important clue to the etiology of this ulcer. He has peripheral neuropathy, which limits his ability to feel the ongoing pressure and friction that affects his feet. Over time, he developed a callous in the area. As he continued walking, the callous was

Sidebar

hard and produced pressure similar to if he had a rock in his shoe; it created an ulcer under it. It is not unusual for a patient with diabetes mellitus to not even realize that he or she has a substantial ulcer on the foot until it becomes infected. Once the callous is removed, the extent of the lesion is revealed. Neuropathic foot ulcers often occur on the plantar aspect of the foot.

Causes: Unknown

       On your rounds, you notice a foul odor coming from the room where a patient was just admitted. In doing the detailed head to toe assessment, you find this lesion on the side of her calf (see Figure 13).

Figure 13

The odor is coming from the wound. As you run through your list of potential etiologies, you know it is not any of the aforementioned ulcers, given the

Table 3

location and shape. A very important step in determining the cause of wound is to know what you do not know. Without further diagnostic studies, you would be unable to determine the etiology. As it turns out, this is melanoma.

The Whole Patient

       The first step to all wound assessment is a thorough head-to-toe evaluation using your eyes and hands. This is most often completed during bathing. Given that some lesions may develop after that procedure, repeat assessments during ongoing care (eg, incontinence cleanup, skin care, and turning) is vital. Recognize that the more typical skin lesions will facilitate appropriate treatment and also allow early detection of the more atypical wounds. Our patients and residents depend on us to spot issues as soon as possible. So keeping our clinical eyes opened and our mental lists running, we can create an early warning alarm for potentially harmful skin issues.