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 patient's 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 "capillary refill."
1-5.
ASSESSING LEVEL OF CONSCIOUSNESS
Level of consciousness should also be assessed upon initial contact with your
patient and continuously monitored for changes throughout your contact with the
patient.
MD0531
1-5