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Lesson 1: Initial Assessment


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The skin is an easily observed indicator of the peripheral circulation and perfusion, blood oxygen levels, and body temperature. The skin color, temperature, and condition are good indicators of the patient's condition and circulatory status. They may also be good initial indicators of heat or cold injuries. This initial indicator should always be confirmed, when time permits, with a core body temperature (see Lesson 2).

a. Color.

(1) Many blood vessels lie near the surface of the skin.

(2) Pigmentation in individuals will not hide changes in the skinís underlying color.

(3) In lightly pigmented individuals, skin normally has a pink color.

(4) In patients with deeply pigmented skin, changes in skin color may only be apparent in certain areas, such as the fingernail beds, the lips, the mucous membranes in the mouth, the underside of the arm and hand, and the conjunctiva of the eye.

(5) Poor peripheral circulation will cause the skin to appear pale, white, ashen, gray, or waxy and translucent like a white candle. These skin colors can also appear in abnormally cold or frozen skin.

(6) When the blood is not properly saturated with oxygen, it changes to a bluish color. Skin over the blood vessels appears blue or gray, a condition called cyanosis.

(7) Red skin will result from carbon monoxide poisoning, significant fever, heatstroke, sunburn, mild thermal burns, or other conditions in which the body is unable to properly dissipate heat.

(8) Color changes may also result from chronic illness. Liver disease dysfunction may cause jaundice, resulting in a yellow cast to the skin.

b. Temperature.

(1) Normally, the skin is warm to the touch.

(2) The skin feels hot with significant fever, sunburn, or hyperthermia.

(3) The skin feels cool in early shock, profuse sweating, heat exhaustion, and profound hypothermia and/or frostbite.

(4) Feel the patientís forehead with the back of your ungloved hand to determine marked fever.

c. Moisture.

(1) The skin is normally dry.

(2) Wet, moist, or excessively dry and hot skin is considered abnormal.

(3) In descriptions of the skin, it is usually listed as color, condition, and temperature (CCT).

d. Capillary Refill. Capillary refill can be assessed as part of the evaluation of the skin.

(1) Capillary refill is used to evaluate the ability of the circulatory system to restore blood to the capillary system (perfusion). Capillary refill is used primarily in the assessment of pediatric patients. Refill time in adults is not considered as accurate due to differences in circulation from medications and various other factors. This can still be used as a simple test of perfusion to the extremities, but many factors must be considered, such as the age of the patient and the environment (cold will decrease capillary refill time).

(2) Capillary refill is evaluated at the nail bed in a finger.

(a) Place your thumb on the patientís fingernail and gently compress.

(b) Pressure forces blood from the capillaries.

(c) Release the pressure and observe the fingernail.

(d) As the capillaries refill, the nail bed returns to its normal deep pink color.

(e) Capillary refill should be both prompt and pink.

(f) Color in the nail bed should be restored within 2 seconds, about the time it takes to say ďcapillary refill.Ē

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