Skin
The body's largest organ, a covering of epidermis over dermis resting on the fatty hypodermis, which holds in fluid, keeps out germs, and helps control body temperature.
Why the exam cares
Once skin breaks, the patient loses a barrier against infection and fluid loss, and most pressure injuries can be prevented by good nursing care. Exam items turn on catching a stage 1 injury early, keeping pressure off bony points, and, in a burn, protecting the airway first and then giving fluid based on burn size.
How to find it
- Pressure injuries form where bone presses skin against a surface: the sacrum and coccyx, heels, hips (greater trochanters), sitting bones (ischial tuberosities), elbows, shoulder blades, and the back of the head.
- Devices make their own pressure points: the ears and bridge of the nose under oxygen tubing or a mask, the chin and back of the head under a cervical collar, and the skin along the edges of a cast or splint.
- Adult rule of nines for burn size: 9 percent each for the head, each arm, the front of each leg, and the back of each leg; 18 percent each for the front and back of the trunk; 1 percent for the perineum.
Pressure point
Staging
Stage 1 is intact skin with redness that does not blanch when pressed; on darkly pigmented skin the nurse looks instead for an area that is warmer or cooler, firmer or softer, or darker than the skin around it. Stage 2 is partial-thickness loss with a shallow pink moist bed or a serum-filled blister, stage 3 is full-thickness loss where fat may be visible, and stage 4 exposes bone, tendon, or muscle. A base hidden by slough or eschar is unstageable, and a persistent deep red, maroon, or purple area or a blood-filled blister is a deep tissue pressure injury.
Pressure point
Prevention
The nurse scores the Braden scale on admission and as often as facility policy directs, turns a patient who cannot move at least every 2 hours, floats the heels off the bed, keeps skin clean and dry, and checks the skin under every device. The nurse never massages a reddened bony area, because rubbing further damages tissue that is already injured underneath.
Emergency
Burns and the airway
Burns of the face or neck, singed nasal hair, soot in the mouth or sputum, hoarseness, or a fire in a closed space point to inhalation injury. Airway swelling can build over hours, so the nurse gives 100 percent oxygen, watches for stridor and a worsening voice, and prepares for early intubation before the airway closes. A normal pulse oximetry reading does not rule out carbon monoxide poisoning, because the device cannot tell carbon monoxide from oxygen on hemoglobin.
Procedure
Burn fluids and circumferential burns
The Parkland formula is 4 mL of lactated Ringer's x kg x percent of body surface with partial- or full-thickness burns (superficial burns are not counted) over 24 hours, with half in the first 8 hours counted from the time of the burn, not from arrival, and the rest over the next 16. The nurse runs fluid through large-bore IV access and tracks hourly urine output, reporting output below about 0.5 mL/kg per hour (about 30 mL per hour in an adult) so the rate can be adjusted. A burn that circles a limb or the chest tightens as it swells, so the nurse checks distal pulses, capillary refill, and sensation, or breathing effort for a chest burn, at least hourly and reports any change at once so an escharotomy can relieve the pressure.