What should be on our temporary care plan for skin integrity?
First, ensure your temporary plan of care is completed within 48 hours of admission.
The skin integrity care plan interventions should be individualized and based on the results of the skin inspection and skin integrity risk assessment. However, there are some interventions that always should be considered on the temporary skin integrity plan of care:
Pressure-redistribution wheelchair cushion
Turning and repositioning schedule and devices
For immobile residents, a means of elevating the heelsof the bed
Incontinence management, with skin kept clean and dry
Referrals as appropriate to Dietary and Therapy
Daily monitoring of the skin condition by caregivers
Head-to-toe weekly skin check performed by licensed nurses
Skin integrity risk assessment per policy
Staff reporting of all skin concerns to the nurse
Notification of the physician/NP and family/designee of any skin concerns that are found
Wound Present? Yes
At a minimum Address the following:
Topical treatment as ordered
Weekly wound assessment by licensed nurses
Monitoring of the wound for signs and symptoms of infection or decline
Notification of the physician/NP and family/designee of any decline, changes in treatment, or concerns.
Once the temporary plan of care is developed, ensure the information is properly communicated and placed on the nursing assistants' care sheets.
Elements of a Comprehensive Skin Assessment
Background: This sheet summarizes the elements of a correct comprehensive skin assessment. You could, for example, integrate them into your documentation system or use this sheet for staff training.
Reference: Developed by Boston University Research Team.
1. Most clinicians use the back rather than the palm of their hand to assess the temperature of a patient's skin.
2. Remember that increased skin temperature can be a sign of fever or impending skin problems such as a Stage I pressure ulcer or a diabetic foot about to ulcerate.
3. Touch the skin to evaluate if it is warm or cool.
4. Compare symmetrical body parts for differences in skin temperature.
1. Ensure that there is adequate light.
2. Use an additional light source such as a penlight to illuminate hard to see skin areas such as the heels or sacrum.
3. Know the person's normal skin tone so that you can evaluate changes.
4. Look for differences in color between comparable body parts, such as left and right leg.
5. Depress any discolored areas to see if they are blanchable or nonblanchable.
6. Look for redness or darker skin tone, which indicate infection or increased pressure.
7. Look for paleness, flushing, or cyanosis.
8. Remember that changes in coloration may be particularly difficult to see in darkly pigmented skin.
1. Touch the skin to see if the skin is wet or dry, or has the right balance of moisture.
2. Remember that dry skin, or xerosis, may also appear scaly or lighter in color.
3. Check if the skin is oily.
4. Note that macerated skin from too much moisture may also appear lighter or feel soft or boggy.
5. Also look for water droplets on the skin. Is the skin clammy?
6. Determine whether these changes localized or generalized.
1. To assess skin turgor, take your fingers and "pinch" the skin near the clavicle or the forearm so that the skin lifts up from the underlying structure. Then let the skin go.
2. If the skin quickly returns to place, this is a normal skin turgor finding.
3. If the skin does not return to place, but stays up, this is called "tenting," and is an abnormal skin turgor finding.
4. Poor skin turgor is sometimes found in persons who are older, dehydrated, or edematous, or have connective tissue disease.
1. Look to see if the skin is intact without any cracks or openings.
2. Determine whether the skin is thick or thin.
3. Identify signs of pruritis, such as excoriations from scratching.
4. Determine whether any lesions are raised or flat.
5. Identify whether the skin is bruised.
6. Note any disruptions in the skin.
7. If a skin disruption is found, the type of skin injury will need to be identified.
Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin problem will need to be determined. For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury?