Module 3 - Hands-on assessment

A skin check is indicated if there is a history of skin breakdown. Many sitting-acquired pressure areas develop against seating support surfaces such as back supports and cushion. A skin check is conducted in supine or side lying position to assess these sites.

The goals of assessing the skin

• To determine the location and shape of the scar tissue or wound
• To check for other scars and skin deformities
• To establish if the skin breakdown is due to pressure from a particular bony prominance against the support surface. For example, while the client in lying in supine or side lying position, simulate the sitting posture by flexing the hips and knees according to the client's postural assessment in the wheelchair. Gently palpate the scar or skin  probelm area to see if it correlates with a suspected bony prominence such as the ischial turberosity ( IT), sacrum and greater trochanter (GT).

Common presentations and possible causes due to support surfaces

• Pressure areas on or near gluteal fold: When the pelvis is posteriorly tilted, the ITs are pointing forward. Check ITs against the crest of ischial well in some cushions. Ensure that the client has good upper limb strength and transfer skill for self-lift or slide board transfer
• Sacrum: With excessive posterior pelvic tilt, there is more upper body weight distrubuted through the sacrum against the support surface, typically the cushion and mattress. Check also for the clearance agasint the push wheel of the manual wheelchair during the self-lift or sliding board transfers
• Underside of GT: check commode seat and "GT off load" type of cushions
• Lateral side of GT: check side lying in bed, and check if GTs are pressing hard against armrest poles
• Heels: check bed, heel loops on footplates, heel scraped by front castor spins
• Lateral border of the foot: external hip rotation, planter flexion and foot inversion may lead to localised pressure or friction on the lateral border of the foot against footplates. Check foot position to allow clearance from flip up hinge of the footplates in wheelchair and commode
• Consider the shape of the scar or wound. If the wound is elongated when compared to the shape of the bony prominence, there is a possibility of shear component

(See Pressure Management in Module 8 for more details)