The Head to Toe Search for Wounds

Search For Wounds Exam Gloves

By Nancy Collins, PhD, RDN, LD, NWCC, FAND

A comprehensive skin assessment should look for more than just wounds because many medical problems have telltale signs that are easy to see if you know what to look for.

POA. These three little letters have become very important in wound care because we must document any wounds present on admission (POA). By doing so, we are saying that these wounds began somewhere else—maybe at home, maybe in another care setting, but definitely not while under the present facility’s care. This distinction of origin has great implications both financially and legally.

The only way to determine if something is POA is to conduct a comprehensive skin assessment. This is a process in which the entire skin of a patient is examined for abnormalities. It requires looking at and touching the skin from head to toe, with a particular emphasis on bony prominences and skin folds.1

One Patient’s Experience

A dissatisfied daughter is now suing her mother’s long-term care facility for what has become the usual trifecta in my work: a nonhealing wound, malnutrition, and dehydration. The daughter claims that her mother was never examined properly nor thoroughly. That is possible because no wounds are documented in the initial nursing notes. In fact, not much is really documented at all—not a bruise, not a skin tear, not a rash. Based on this, all of the ensuing skin integrity problems are assumed to have started in the long-term care facility. It is impossible to go back in time and say for sure, so we have to believe the medical record.

Malnutrition and dehydration claims are a little trickier because these problems develop over the course of time. Malnutrition tends to manifest as unintended weight loss that happens over weeks and months. Dehydration sometimes is more sudden, but in either case, if you do not know what to look for or are not looking for it, you will never find it. And if you never find it, you will never document it. In reviewing the case, we found that this patient had lost 35 pounds over the course of 3 months. The daughter was desperate to know how the caregivers did not “see” this.

Seeing the Problem

I started thinking about why we do not “see” the problems and asked some of my colleagues what they thought. I heard a wide variety of justifications for this apparently common problem. Nurses are busy, there is a lot of documentation to do, and patients do not always cooperate. One interesting reason that kept coming up was the fact that my colleagues really did not know what to look for beyond an obviously open area in the skin. When I asked what they do they look for to detect nutritional deficiencies, most replied body weight.

While scale weight can indicate problems, it is not very helpful during an initial assessment when there usually is not any reliable weight history for comparison. In order to properly and individually treat each patient, caregivers need to do a little more detective work and look for other telltale signs of immediate or developing problems.

The following are just a few signs that you can easily see during a comprehensive skin assessment: 2  

  • Pale skin and thin, concave nails may indicate an iron deficiency
  • Something that looks like goose bumps but does not go away when you rub the skin is possibly follicular hyperkeratosis caused by a vitamin A deficiency
  • Bitot’s spots on the eyes also can result from a vitamin A deficiency
  • Dry, cracked, swollen lips or tongue inflammation often are caused by vitamin B deficiencies
  • Bleeding gums may indicate a vitamin C deficiency
  • Small hemorrhages in the skin or mucous membranes may mean a vitamin K problem
  • Malaise, mental confusion, tense calf muscles, distended neck veins or jerky movement of the eyes may indicate a thiamine deficiency
  • Hollows, depressions, or loose skin around the eyes can show fat loss
  • A depression or pit at the temples may mean muscle loss

There are dozens of signs of nutritional and medical problems if you look for them.

I am sure every wound care practitioner has attended a lecture where the speaker said the skin is the largest organ. As such, wound care professionals are in the unique position to detect a lot more than just pressure injuries and skin tears. Looking at the skin means looking at the patient as a whole and that will go a long way toward improving outcomes.

References and Additional Resources

  1. Morgan N. Comprehensive skin assessment. Wound Care Advisor website.  
  2. Martin C. Nutrition-focused physical exam: the micronutrient deficiency detective. Today’s Geriatric Medicine. 2017;10(5):22.