Wednesday, November 17, 2010

Skin Assessment - Excelsior's 17th Edition CPNE Study Guide pg 203 - 205

Assess at least 2 bilateral vulnerable skin surfaces. Examples are right and left heels and right and left hips, or bilateral ears and occipital region, coccyx and bilateral elbows. The idea is that if the area has a corresponding opposite - right and left it only counts as one site.

When assessing check the color - is the area pink, red, blue, black?; temperature - is the area warm, hot, cool. or hot?;  integrity - is the skin intact, are there abrasions, rashes, lesions?, moisture - is the area moist, dry, diaphoretic and sweaty or flaky? is the area prone to breakdown from incontinence or sheet sheering when repositioning?

Document all finding include any abnormalities and paint a picture. Be specific with size in cm or mm, color, edema, weeping, and what you did to address the problem, repositioned to relieve pressure, elevated on pillow, pericare to clean incontinence. Document the position the patient was in originally and the position you left the patient in. Report to primary nurse and deviation for baseline.

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