Chapter 8: Assessment and Observation of the Musculoskeletal and Integumentary Systems

Introduction

The musculoskeletal and integumentary systems are the last two systems a nurse considers during their observation and assessment of a patient. It is important that nurses are able to accurately and comprehensively assess these systems, and this chapter introduces the fundamental knowledge and skills nurses require to do so. This chapter explores the fundamental anatomy and physiology of the musculoskeletal and integumentary systems. This chapter also explains the processes involved in collecting a general health history for the musculoskeletal and integumentary systems, and in performing a physical examination of these systems. This chapter also considers a number of special observation and assessment techniques which may be used in the physical examination of the musculoskeletal and integumentary systems, and it discusses performing differential diagnosis relevant to these systems.

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the basic anatomy and physiology of the musculoskeletal and integumentary systems.

-To explain how to collect a focused health history related to the musculoskeletal and integumentary systems.

-To explain how to undertake a physical examination of the musculoskeletal and integumentary systems.

-To recognise the common problems / conditions related to the musculoskeletal and integumentary systems, and their typical clinical findings, to enable differential diagnosis.

-To describe the variety of special assessment techniques which may be used in the physical examination of the musculoskeletal and integumentary systems.

Important note

This section of the chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

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Fundamental anatomy and physiology of the musculoskeletal system

The musculoskeletal system provides the body with support, enables mobility and protects the internal organs. The musculoskeletal system is comprised of:

  • The skeleton - the system of bones. Each bone has a different function, and this dictates its shape and features; for example, long bones act as levers, have a flat surface for attachment of the muscles, and grooves to allow the passage of tendons / nerves. Bones may also be described as short, flat or irregular. The skeleton has two major divisions: (1) the axial skeleton, which includes the bones in the central body structure (e.g. skull, vertebrae, ribs, sternum, pelvis, etc.), and (2) the appendicular skeleton, which includes the bones of the appendages (e.g. upper extremities [arms, hands], lower extremities [legs, feet], etc.).
  • The muscles. Muscles attach to bones to facilitate movement.

Joints are areas where two or more bones meet; they act to allow movement between these bones. Joints are classified in two ways: (1) by the type of material between them (e.g. synovial, cartilaginous, fibrous), and (2) by the type of movement they allow (e.g. immoveable - synarthrodial, slightly moveable - amphiarthrodial, freely moveable - diarthrodial). Diarthrodial joints are further classified by their type of movement (e.g. hinge joints, pivot joints, condyloid / ellipsoidal joints; ball-and-socket joints, gliding joints, etc.).

The musculoskeletal system is supported by:

  • Ligaments - strong, flexible bands of connective tissue which hold bone to bone.
  • Tendons - strong, non-elastic cords of collagen which attach muscle to bones.

Other key structures in the musculoskeletal system are cartilage and bursae. Cartilage is a smooth, gel-like, avascular tissue that is highly flexible, and allows some degree of movement in the bones. Bursae are sacs in the connective tissue adjacent to some joints (e.g. the shoulders), which contain synovial fluid and act as a lubricant to reduce friction between bones, muscles and associated structures.

Musculoskeletal system - focused health history

As you have seen in previous chapters of this module, health observation and assessment involves three concurrent steps:

When assessing a patient's musculoskeletal system, the nurse must commence by collecting a health history. This involves collecting data about:

Component

Rationale

Present health status

Chronic illnesses, even if they are not related directly to dysfunction in the musculoskeletal system, can cause damage to this system. There are some diseases related directly to the musculoskeletal system - such as osteoporosis, arthritis, etc. - of which the nurse must take particular note.

Current medications, either prescribed or over-the-counter, which: (1) may be taken to treat pre-existing musculoskeletal problems, and / or (2) may cause side effects which affect the musculoskeletal system. Nurses should be aware that patients frequently take analgesics and anti-inflammatory medications to control pain and other symptoms in the musculoskeletal system.

Exercise, as lack of exercise, as per UK national guidelines, is a key risk factor for musculoskeletal dysfunction.

Recent changes in movement / mobility, as this can provide a nurse with important information about possible causes of dysfunction in the musculoskeletal system, and also issues to be aware of during the physical examination.

Past medical history

Injuries to, or illnesses of, the musculoskeletal system, as these may leave a client with deficits which a nurse can anticipate finding during the physical examination.

Surgery on the musculoskeletal system, as this can provide a nurse with additional information on possible gastrointestinal / urinary system problems the client has or has had.

Family history

Family history of diseases affecting the musculoskeletal system (e.g. arthritis, osteoporosis, etc.), especially among first-degree relatives, as this can provide important information about the types of disease for which a person may have a congenital risk.

In some cases, a person will present with a specific problem related to their musculoskeletal system (e.g. pain, problems with movement and difficulties with activities of daily living [which may be generalised or specific], etc.). Remember, nurses assess a patient's symptoms using the strategy remembered by the 'OLD CARTS' mnemonic (introduced in a previous chapter of this module).

Musculoskeletal systems - physical examination

Once a health history of the musculoskeletal system has been obtained, as described in the previous section of this chapter, a nurse may commence a physical examination of the patient's musculoskeletal system. A stepwise process of physically examining the patient's musculoskeletal system, with normal (expected) and common abnormal findings, is presented in the following table:

Component

Normal (Expected) Findings

Abnormal Findings

Inspect the axial and appendicular skeletons for alignment, contour, symmetry, size, gross deformities.

The client should stand erect; the body is relatively symmetric; the spine is straight with normal curvatures; the hips, knees and ankles in a straight line; the feet are flat on the floor.

Irregular posture; asymmetry; misalignment, etc.

Inspect the muscles for size and symmetry.

The muscles should be relatively symmetric bilaterally.

Atrophy of the muscles (unilaterally, bilaterally); fasciculations (muscle twitching); irregular posture; asymmetry; misalignment, etc.

Palpate the bones and muscles for tenderness, heat, oedema.

Bones and muscles should be non-tender; no oedema should be identified; tissues should feel firm (not hard or soft); tissues should be the same temperature as the surrounding tissues.

Tenderness; heat; oedema; atrophy, etc.

Assess the range of motion of each of the main joints (using the technique described later in this chapter).

There should be full range of motion of each joint without crepitus, deformity, contracture or pain.

Crepitus; deformity; contracture; pain; joint instability; weakness; increased / decreased range of motion, etc.

Test the muscles for strength bilaterally (using the technique described later in this chapter).

Normal strength for the muscle tested; bilaterally symmetric; full resistance to opposition.

Muscle weakness; muscle cramping / contracture.

Observe gait for conformity, symmetry, rhythm.

Conformity (i.e. ability to follow gait sequencing); regular smooth rhythm; symmetry of steps / arm swing; smooth swaying movements.

Unstable / exaggerated gait; limp / irregular stride; arm swing unrelated to gait; inability to maintain straight posture; symmetry, etc.

Palpate the temporomandibular joint for movement, sounds, tenderness.

The mandible (jaw) should move smoothly and painlessly; audible or palpable clicking without pain is normal.

Difficulty opening the mouth; pain or crepitus; locking of the jaw, etc.

Percuss the spine for tenderness.

No tenderness should be noted.

Tenderness; inflammation; heat; oedema; muscle spasm, etc.

Special assessment techniques for the musculoskeletal system

There are a number of special assessment techniques particular to the musculoskeletal system:

  • Range of motion: this involves moving a joint through its full range of normal, expected movements. As you saw in an earlier section of this unit, there are a variety of different types of joints, and each type has its own expected movement - for example: immoveable - synarthrodial, slightly moveable - amphiarthrodial, freely moveable - diarthrodial: hinge joints, pivot joints, condyloid / ellipsoidal joints; ball-and-socket joints, gliding joints, etc. It is important that nurses are familiar with the expected movement of the joint they are assessing.
  • Muscle strength: the client should be asked to flex a muscle, and to resist when the nurse applies opposing force to the muscle. Muscle strength is often rated on a scale of 0 (no capacity to resist an opposing force) to 5 (full capacity to resist an opposing force). A client's muscle strength should be bilaterally symmetric.

Differential diagnosis in the musculoskeletal system

When assessing a patient's musculoskeletal system, there are a number of common problems and conditions a nurse may identify. Consider the conditions and their key clinical findings, outlined in the following table. This information can be useful in assisting a nurse to make a differential diagnosis of a condition affecting the musculoskeletal system:

Integumentary Problem or Condition

Typical Clinical Findings

Fracture - this occurs when there is a partial or complete break in a bone.

Pain; muscle spasm; deformity; loss of function; shortening of the tissue around the affected bone; localised oedema, etc.

Osteoporosis - a condition involving osteopenia (i.e. loss of bone density) and decreased bone strength.

May occur without signs / symptoms; loss of height; spontaneous (pathologic) fracture; kyphosis (convex curvature of thoracic spine), etc.

Arthritis - a condition involving chronic inflammation of the connective tissue.

Gradual onset of joint pain; joint stiffness; joint inflammation; reduced range of motion; fatigue, etc. May be rheumatoid arthritis, osteoarthritis, etc.

Bursitis - an inflammation of the bursae, due to constant friction.

Sudden onset of joint pain; joint stiffness; joint inflammation; reduced range of motion; fatigue, etc.

Gout - a condition involving an increase in serum uric acid.

Oedema, erythema of affected joint; reduced range of motion; tophi (deposits of uric acid in the joints); nephrolithiasis, etc.

Scoliosis - a condition involving an S-shaped deformity of the spine, due to congenital malformation, neuromuscular disease, traumatic injury, etc.

Uneven / asymmetric shoulders and hips; rotation; rib / shoulder hump; possible dysfunction of the lungs, pelvis, central nervous system, etc.

Carpal tunnel syndrome - compression of a nerve between the carpal ligament and other structures in the carpal tunnel.

Burning, numbness, tingling of the affected hand, etc. Often follows a prolonged period of repetitive hand movements.

Fundamental anatomy and physiology of the integumentary system

The integumentary system is comprised of the skin and accessory structures - the hair, the nails and the sweat and sebaceous glands. The skin is the main organ in the integumentary system. Its primary function is to protect the body from external pathogens, and to protect the internal structures from water loss and physical trauma. The skin also provides sensory input, regulates body temperature, produces vitamin D and excretes some substances (e.g. urea, lactic acid, etc.). It is comprised of three layers:

  • The epidermis - the thin, avascular outer layer comprised of keratinised cells.
  • The dermis - comprised of highly vascular connective tissue and sensory nerve fibres.
  • The subcutaneous layer - the support structure for the dermis / epidermis, comprised of connective tissue and subcutaneous fat.

The integumentary system also includes a number of accessory structures:

  • The hair. Each hair consists of a root (extending into the dermis), a follicle and a shaft.
  • The nails: layers of kertinised epidermal cells which function to protect the appendages.
  • The sweat and sebaceous glands. These include eccrine and apocrine sweat glands, which secrete sweat and other odorous fluids onto the surface of the body, and the sebaceous glands, which secrete oily sebum to prevent the drying of the skin / hair.

Integumentary system - focused health history

As always, when assessing a patient's integumentary system, the nurse must commence by collecting a health history. This involves collecting data about:

Component

Rationale

Present health status

Chronic illnesses, even if they are not related directly to dysfunction in the integumentary system, can cause damage to this system. In particular, chronic illnesses (e.g. liver failure, renal failure, autoimmune disease) can result in pruritus, skin lesions, dryness, etc.

Current medications, either prescribed or over-the-counter, which: (1) may be taken to treat pre-existing integumentary system problems, and / or (2) may cause side effects which affect the integumentary system.

Current skincare practices - including hygiene measures, use of lotions and sun protection strategies, etc. as this provides a nurse with important information about possible underlying problems with the integumentary system, and also requirements for health education.

Changes in the way the skin looks / feels; again, this provides a nurse with important information about possible underlying problems with the integumentary system.

Past medical history

Injuries to, or illnesses of, the integumentary system, as these may leave a client with deficits which a nurse can anticipate finding during the physical examination.

Surgery on the integumentary system, as this can provide a nurse with additional information on possible integumentary system problems the client has or has had.

Family history

Family history of diseases affecting the integumentary systems (e.g. skin cancer, autoimmune skin conditions, etc.), especially among first-degree relatives, as this can provide important information about the types of disease for which a person may have a congenital risk.

In some cases, a person will present with a specific problem related to their reproductive system (e.g. pruritus, rashes, pain / discomfort, lesions, wounds, changes in colour / texture of the skin / hair / nails, etc.). Remember, nurses assess a patient's symptoms using the strategy remembered by the 'OLD CARTS' mnemonic (introduced in a previous chapter of this module).

Integumentary system - physical examination

Once a health history of the integumentary system has been obtained, as described in the previous section of this chapter, a nurse may commence a physical examination of the patient's integumentary system. A stepwise process of physically examining the integumentary, with normal (expected) and common abnormal findings, is presented in the following table:

Component

Normal (Expected) Findings

Abnormal Findings

Inspect the skin for general colour.

The skin colour should be consistent with the person's ethnicity, and consistent over the body surface (though sun-exposed areas may be darker). Freckles, moles and striae are all normal findings.

Cyanosis; ecchymosis; erythema; jaundice; pallor; petechiae, etc. (Refer to the information provided later in this chapter).

Palpate the skin for texture, temperature, moisture, mobility, turgor, thickness, lesions.

Skin texture should be smooth, soft and intact, with an even surface; some callouses are normal on the hands / feet / elbows / knees. Skin temperature should be consistent, and may be cooler at the extremities; skin is dry, with minimal perspiration or oiliness; skin is elastic; no lesions are present.

Excessive dryness; flaking / cracking / scaling; maceration; discolouration; rashes; excessively cool or hot skin; diaphoresis; excessively moist skin; oedema; poor skin turgor (e.g. 'tending'); excessively thick or thin skin; lesions, etc.

Inspect the hair on the head and the body for characteristics, distribution, quantity, colour, texture.

Hair should be shiny and soft; may be fine or coarse; a variety of normal colours may be seen; symmetric distribution.

Dull / coarse / brittle hair; alopecia (hair loss); broken hair shafts, etc.

Inspect and palpate the nails for shape, contour, consistency, colour, thickness, cleanliness.

Nail edges should be smooth and rounded; nail surface should be flat in the centre and slightly curved at the edges; skin adjacent to the nails should be intact.

Inflammation / oedema / erythema of the nails / surrounding tissues; spooned nails; banding; pitting; leukonychia (white spots); clubbing (as described in a previous chapter of this module).

As described in the above table, when performing a physical examination of the integumentary system, it is important that nurses inspect the skin for colour. There are a number of abnormal findings associated with skin colour:

Clinical Finding

Light-Skinned People

Dark-Skinned People

Cyanosis

Greyish-blue tone of the nail beds, earlobes, lips, mucous membranes, palms, soles of the feet, etc.

Ashen-grey colour in the conjunctive, oral mucous membranes, nail beds, etc.

Ecchymosis (bruising)

Dark red / purple / yellow / green colour (depending on the age of the bruise).

Deeper purple / blue / black tone; may be difficult to see.

Erythema

Reddish tone; evidence of increased skin temperature; inflammation.

Deeper brown / purplish skin tone; increased skin temperature; inflammation.

Jaundice

Yellowish colour of the skin, sclera, fingernails, palms, soles of the feet, oral mucosa, etc.

Yellowish colour of the sclera, fingernails, oral mucosa, etc.

Pallor

Pale skin colour.

Skin tone will appear lighter than normal; ashen.

Petechiae

Small (pinpoint), reddish-purple lesions.

Very difficult to see - may be evident as small (pinpoint), reddish-purple lesions in the buccal mucosa or sclera.

Also described in the above table, when performing a physical examination of the integumentary system, it is important that nurses inspect the skin for lesions. There are a number of abnormal findings associated with lesions:

Lesion Type

Description

Macule

A flat, circular area of skin, less than 1 centimetre in diameter, where there is a change in skin colour (e.g. a freckle, flat mole, petechiae, measles, etc.).

Papule

An elevated, firm area less than 1 centimetre in diameter (e.g. a wart, elevated mole, cherry angioma, skin tag, etc.).

Patch

A flat, irregular-shaped macule of more than 1 centimetre in diameter (e.g. vitiligo, 'port wine stain', Mongolian spot, etc.).

Plaque

An elevated, rough lesion with a flat surface greater than 1 centimetre in diameter (e.g. psoriasis, eczema, keratosis, etc.).

Wheal

An elevated, irregular-shaped area of cutaneous oedema (e.g. insect bite, urticarial, allergic reaction, etc.).

Nodule

An elevated, firm lesion, deeper in the dermis than a papule, and 1-2 centimetres in diameter (e.g. a lipoma, melanoma, haemangioma, etc.).

A tumour

An elevated, solid lesion, may or may not be clearly demarcated, deeper in the dermis, >2 centimetres in diameter (e.g. neoplasm, lipoma, haemangioma, etc.).

A vesicle

An elevated, superficial lesion, not into the dermis, filled with serous fluid, <1 centimetre in diameter (e.g. varicella ['chicken pox'], herpes zoster [shingles], impetigo, eczema, etc.).

Bulla

A vesicle >1 centimetre in diameter (e.g. a blister, impetigo, etc.).

Pustule

An elevated, superficial lesion, similar to a vesicle but filled with purulent fluid (e.g. impetigo, acne, folliculitis, herpes simplex, etc.).

Cyst

An elevated, encapsulated lesion, in the dermis or subcutaneous layer, filled with liquid / semisolid material (e.g. sebaceous cyst).

Scale

An accumulation of keratinised cells, flaky skin, thick or thin, dry or oily and variable in size (e.g. flaking of skin with seborrheic dermatitis, dry skin, eczema, etc.).

Lichenification

Roughened, thickened epidermis secondary to persistent rubbing / itching / skin irritation (e.g. chronic dermatitis).

Keloid

An irregular, elevated, progressively enlarging scar which grows beyond the boundaries of the wound (e.g. post-surgery keloid).

Scar

A fibrous band of tissue that replaces normal tissue following injury to the dermis (e.g. healed wound, old surgical incision site, etc.).

Excoriation

Loss of the epidermis in a linear, hollowed-out area (e.g. a scratch).

Fissure

A linear crack or break in the epidermis / dermis, which may be moist or dry (e.g. chapped hands, eczema, 'Athlete's foot', etc.).

Crust

Dried drainage or blood, slightly elevated and variable in size (e.g. a scab on an abrasion, eczema, etc.).

Erosion

A loss of part of the epidermis in a depressed, moist area, often due to rupture of a vesicle or bulla (e.g. after rupture of varicella, candidiasis, herpes simplex lesions, etc.).

Ulcer

The loss of the epidermis and dermis in a concave area (e.g. a pressure ulcer, venous stasis ulcer, syphilis chancre, etc.).

Atrophy

Thinning of the skin surface (e.g. in aged skin, striae, etc.).

Angioma

A benign tumour, varying in size, consisting of a small mass of blood vessels (e.g. a 'cherry' angioma, haemangioma, etc.).

Pressure ulcer

These are cased by unrelieved pressure on, and resulting hypoxia and necrosis of, the tissues overlying a bony prominence (e.g. the sacrum). Pressure ulcers are very common in clinical settings in the United Kingdom; however, it is important for nurses to bear in mind that these are completely preventable and treatable. You will study pressure ulcers in greater detail in the 'hands-on scenario' which accompanies this chapter.

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Special assessment techniques for the integumentary system

There is one special assessment technique particular to the integumentary system - assessing skin turgor. This is done by gently pinching the skin on the forearm or under the clavicle, lifting it away from the underlying tissues, and releasing it; the skin should move easily when lifted and should return to its original place immediately when released. Skin turgor may be poor if 'tenting' occurs (i.e. skin returns to its original place very slowly).

Differential diagnosis in the integumentary system

When assessing a patient's integumentary system, there are a number of common problems and conditions a nurse may identify. Consider the conditions and their key clinical findings, outlined in the following table. This information can be useful in assisting a nurse to make a differential diagnosis of a condition affecting the integumentary system:

Integumentary Problem or Condition

Typical Clinical Findings

Hyperkeratosis (a 'corn') - a lesion that develops due to chronic pressure on the foot from a shoe (usually over a bony prominence).

Flat or slightly raised, painful lesion with a smooth, hard surface; lesion may be soft (usually on the fourth, fifth toes) or hard.

Dermatitis - a superficial inflammation of the skin.

Red, weeping, crusted lesions; usually localised to the hands / feet / face; erythema; oedema; wheals; scales; vesicles; pruritus; petechiae, etc.

Psoriasis - an inflammatory skin condition.

Slightly raised, erythematous plaques; scales; most often on the elbows / knees / buttocks / lower back / scalp; pruritus; burning; bleeding, etc.

Warts - a benign lesion caused by the human papilloma virus (HPV).

Round, irregular-shaped papular lesions; light grey, yellow, brownish-black skin discolouration; most common on the fingers, hands, elbows, knees, etc.

Herpes simplex virus (HSV) - a viral infection of the skin.

A group of vesicles on erythematous skin; HSV-1 lesions often on the upper lip / nose / skin around the mouth / tongue (may be referred to as a 'cold sore'); HSV-2 lesions usually appear in the genitalia.

Herpes varicella virus - a viral infection, commonly referred to as 'chicken pox' resulting in lesions in the skin.

Lesions progress from macules to papules to vesicles, which eventually erupt and crust; usually appear on the trunk and then on the extremities.

Herpes zoster virus - a viral infection, commonly referred to as 'shingles' resulting in lesions in the skin.

Linear vesicles which appear along a cutaneous sensory nerve; these become pustules and eventually crust; this is a very painful condition.

Tinea - an infection with one or more of the tinea funguses.

Appears as circular patches or vesicles on various parts of the body; accompanied by discomfort, itching, etc.

Candidiasis - an infection with the Candida albicans fungus.

Scaling red rash; sharply demarcated borders; large patch with some loose scales; commonly in the genitalia, inguinal areas, gluteal folds, etc.

Impetigo - an infection with staphylococcal / streptococcal bacteria.

An erythematous macule that becomes a vesicle / bullae and ruptures; commonly on the face / nose / mouth, though other skin areas may be involved.

Folliculitis - an inflammation of the hair follicles.

An acute lesion, with erythema and a pustule, surrounding a hair follicle; common on the scalp and extremities.

Furuncle, abscess or boil - a localised infection caused by staphylococcal bacteria.

A nodule surrounded by erythema, oedema; progresses to a pustule; surrounding skin is erythematous, hot, tender.

Skin carcinoma - a cancer of the skin cells.

A lesion which is unusual, which may present as a growth or a sore, which doesn't go away; may be associated with changes in the colour / texture of the skin; may or may not be painful, etc.

Conclusion

The musculoskeletal and integumentary systems are the last two systems a nurse considers during their observation and assessment of a patient. It is important that nurses are able to accurately and comprehensively assess these systems, and this chapter has introduced the fundamental knowledge and skills nurses require to do so. This chapter has explored the fundamental anatomy and physiology of the musculoskeletal and integumentary systems. This chapter has also explained the processes involved in collecting a general health history for the musculoskeletal and integumentary systems, and in performing a physical examination of these systems. This chapter also considered a number of special observation and assessment techniques which may be used in the physical examination of the musculoskeletal and integumentary systems, and it discussed performing differential diagnosis relevant to these systems. In completing this chapter, you have equipped yourself with the skills and knowledge necessary to comprehensively assess the musculoskeletal and integumentary systems.

Reflection

Now we have reached the end of this chapter, you should be able:

-To describe the basic anatomy and physiology of the musculoskeletal and integumentary systems.

-To explain how to collect a focused health history related to the musculoskeletal and integumentary systems.

-To explain how to undertake a physical examination of the musculoskeletal and integumentary systems.

-To recognise the common problems / conditions related to the musculoskeletal and integumentary systems, and their typical clinical findings, to enable differential diagnosis.

-To describe the variety of special assessment techniques which may be used in the physical examination of the musculoskeletal and integumentary systems.


'Hands-on scenario': Assessment of a pressure ulcer.

Jack is a graduate nurse working in an acute ward in a large tertiary hospital. During one shift, he cares for a patient named Mary. Mary is a sixty-eight-year-old woman who has advanced metastatic cancer and is bedbound. Mary has recently developed a large pressure ulcer on her sacrum.

Jack knows that pressure ulcers occur when there is unrelieved pressure on an area of the body, resulting in progressive tissue ischaemia and necrosis. Jack also knows that pressure ulcers are entirely preventable; however, when they do occur, they can be effectively managed. The first step in the management of Mary's pressure ulcer is to assess it.

Activity

You are encouraged to read the National Institute for Health and Clinical Excellence's (NICE) Pressure Ulcers: Prevention and Management (2014) guideline, or the current equivalent. This guideline can be obtained online, by searching for its title.

Jack refers to the National Institute for Health and Clinical Excellence's (NICE) Pressure Ulcers: Prevention and Management (2014) guideline. This guideline states that pressure ulcers must be assessed in three different ways:

  • "Document the surface area of all pressure ulcers in adults… us[ing] a validated measurement technique (for example, transparency tracing or a photograph)" (p. 21).

Jack refers to his organisation's wound care management team, and discovers that transparency tracing is the standard measurement technique used to assess pressure ulcers.

5.5cm wide

7.2cm long

This involves laying a specially designed, sterile transparent film over a wound, and using a marker to trace the borders of the wound directly onto the film (as illustrated to the left). The longest and widest parts of the wound are also measured and recorded.

A sequence of multiple films can be compared to show changes in the size of the wound over time. With Mary's informed consent, Jack completes the first transparency tracing of her pressure ulcer, and stores it, clearly marked, her documentation.

  • "Document an estimated of the depth of all pressure ulcers and the presence of undermining, but do not routinely measure the volume of a pressure ulcer" (p. 21).

While completing the wound tracing, Jack also estimates the depth of Mary's pressure ulcer at 6 millimetres (at the deepest point). He records this in Mary's notes. Jack assesses for areas of undermining, where the ulcer has tunnelled - or forms a tract - into the tissues beneath and around it; he does so by carefully exploring the edges of the wound with the end of a sterile probe to identify areas of weakness. No undermining is noted, and Jack again records this in Mary's notes.

  • Categorise each pressure ulcer in adults using a validated classification tool (such as the International NPUAP-EPUAP Pressure Ulcer Classification System). Use this to guide ongoing preventative strategies and management. Repeat and document each time the ulcer is assessed" (p. 21).

Activity

You are encouraged to read the National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Ulcer Stages / Categories (2009) document, or the current equivalent. This document can be accessed online, by searching for its title.

Jack accesses the National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Ulcer Stages / Categories (2009) document. He learns that pressure ulcers are staged as follows:

Pressure Ulcer Stage

Description

Deep tissue injury

Localised area of discoloured tissue (purple, maroon); usually overlying a bony prominence; as a result of pressure / shear.

Stage I

Localised area of red, non-blanchable skin; usually overlying a bony prominence; skin is intact.

Stage II

Partial thickness loss of the dermis; a shallow, open ulcer with a pink / red bed OR an intact, serum-filled blister; no slough.

Stage III

Full thickness tissue loss; may have visible subcutaneous fat (but no visible bone, tendon, muscle); may have slough; may include undermining.

Stage IV

Full thickness tissue loss; exposed bone, tendon and / or muscle; may have slough or eschar; often includes undermining.

Unstageable

Full thickness tissue loss; base of the ulcer is covered in slough yellow, tan, grey, green, brown) and / or eschar (tan, brown, black) which prevents staging.

Based on the NPUAP guidelines, Jack classifies Mary's ulcer as a Stage II ulcer. Jack observes a partial thickness loss of the dermis. There is a shallow, open ulcer with a pink wound bed, and no slough. Jack records this in Mary's notes. Now that his assessment of the ulcer is complete, he can discuss the findings with Mary and her interdisciplinary care team, and plan for management of her ulcer.

As well as assessing a pre-existing ulcer, as described in this hands-on scenario, nurses like Jack must be aware of the importance of carrying out a pressure ulcer risk assessment. The aim of a pressure ulcer risk assessment is: (1) to identify a patient at particular risk of developing a pressure ulcer, and (2) to enable strategies to be implemented to prevent the development of a pressure ulcer in that patient. Remember: all patients are potentially at risk of developing a pressure ulcer; however, some experience a greater risk than others. The National Institute for Health and Clinical Excellence's (NICE) Pressure Ulcers: Prevention and Management (2014) guideline suggests that people are at particular risk of the development of pressure ulcers if they:

  • Have significantly limited mobility.
  • Experience a significant loss of sensation.
  • Have a current, or have had a previous, pressure ulcer.
  • Have a nutritional deficiency.
  • Are unable to reposition themselves.
  • Have a significant cognitive impairment.
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When assessing the risk of a patient developing a pressure ulcer, nurses should "consider using a validated scale to support [their] clinical judgement" (National Institute for Health and Clinical Excellence, 2014: p. 13). There are two validated pressure ulcer risk assessment tools which may be used in clinical settings in the UK:

  • The Waterlow scale, which scores a patient's risk of developing a pressure ulcer on a scale of 1-64. A Waterlow score of ≥10 indicates a risk of the development of a pressure ulcer, a score of ≥15 indicates a high risk, and a score of ≥20 indicates a very high risk. When assigning a patient's a risk score, the Waterlow scale considers the patient's weight for height (i.e. Body Mass Index), skin type, gender, age, malnutrition score, continence and mobility; higher risk patients are also assessed according to their level of tissue malnutrition, degree of neurological deficit and presence of tissue trauma, etc.
  • The Braden scale, which scores a patient's risk of developing a pressure ulcer on a scale of 6-23. A lower Braden score indicates a lower level of functioning and, subsequently, a high risk of developing a pressure ulcer. When assigning a patient with a risk score, the Braden scale considers the person's sensory perception, degree of the skin's exposure to moisture and friction / shear, degree of physical activity and mobility, and nutrition. 

Reference list

Cox, C. (2009). Physical Assessment for Nurses (2nd edn.). West Sussex, UK: Blackwell Publishing, Ltd.

Jensen, S. (2014). Nursing Health Assessment: A Best Practice Approach. London, UK: Wolters Kluwer Publishing.

National Institute for Health and Clinical Excellence. (2014). Pressure Ulcers: Prevention and Management. Retrieved from: https://www.nice.org.uk/guidance/cg179/resources/pressure-ulcers-prevention-and-management-35109760631749

National Pressure Ulcer Advisory Panel (NPUAP). (2009). Pressure Ulcer Stages / Categories. Retrieved from: http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Pressure-Ulcer-Stages-Categories.pdf

Wilson, S.F. & Giddens, J.F. (2005). Health Assessment for Nursing Practice (4th edn.). St Louis, MI: Mosby Elsevier.


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