Scaling Thickening (Atrophy) of the subcutaneous tissue Nurse signature: Date: Thickening of nails/ slow nail growth Assess for signs of skin damage, Poor tissue nutrition/ oxygenation caused particularly from injury. by chronic reduction in arterial blood Ulceration or necrosis may be supply results in skin changes. present, particularly over pressure areas such as heels, dorsum of foot and metatarsal heads. Nurse signature: Date: Assess for oedema. Pitting oedema may indicate congestive Examine for size, symmetry and cardiac failure or renal failure. Ischaemic presence of oedema. rest pain may cause the patient to hold Press the skin firmly for 5 seconds to the limb dependant with associated identifywhether it is pitting. oedema in the leg. The patient may sleep in the chair or hang the leg out of bed to gain relief. Nurse signature: Date: A capillary refill time of more than 5 Capillary refill Also known as the blanch test. Apply seconds is considered abnormal and pressure to the nail of a digit until the indicates poor peripheral perfusion. digit loses colour. On release of pressure, if the patient has good cardiac output and digital perfusion, the refill time should be less than 3 seconds. Nurse signature: Date: Assess skin temperature Severe arterial insufficiency will result in a Ensure room temperature is not too cool limb.
Scaling Thickening (Atrophy) of the subcutaneous tissue Thickening of nails/ slow nail growth Nurse signature: Date: Assess for signs of skin damage, particularly from injury. Ulceration or necrosis may be present, particularly over pressure areas such as heels, dorsum of foot and metatarsal heads. Poor tissue nutrition/ oxygenation caused by chronic reduction in arterial blood supply results in skin changes. Nurse signature: Date: Assess for oedema. Examine for size, symmetry and presence of oedema. Press the skin firmly for 5 seconds to identifywhether it is pitting. Pitting oedema may indicate congestive cardiac failure or renal failure. Ischaemic rest pain may cause the patient to hold the limb dependant with associated oedema in the leg. The patient may sleep in the chair or hang the leg out of bed to gain relief. Nurse signature: Date: Capillary refill Also known as the blanch test. Apply pressure to the nail of a digit until the digit loses colour. On release of pressure, if the patient has good cardiac output and digital perfusion, the refill time should be less than 3 seconds. A capillary refill time of more than 5 seconds is considered abnormal and indicates poor peripheral perfusion. Nurse signature: Date: Assess skin temperature Ensure room temperature is not too Severe arterial insufficiency will result in a cool limb.