[jonear2]

My patients look at me like I am crazy when I ask them to turn to the side to listen to their lungs and check the skin on their backs/bottoms. I am very honest with them that I am making sure that they dont have any skin sores or rashes but some of them really give me this look. And some of them have told me that I was the only one to ever ask them to do this, like I am some sort of perv. And it really freaks some of them out when I go to touch a reddened area to check blanching. I always tell them I am going to touch before I do, but still. Some of the other nurses say I dont have to be so militent about checking for decubs on 30 year old walkie talkies but hello there are other skin issues that could be happening, herpes lesions for example, and I dont want that to come back on me. i guess my question is... does anyone have any suggestions for better ways to present the subject to the patients so that they dont look at me like Im crazy?

[ljds]

I work on an acute medical floor. I NEVER check the skin on someone's bum unless they are at risk for skin breakdown--incontinent, immobile, dependent edema, loss of sensation, or history of previous decub all comes to mind. I would NEVER check the skin of someone who is a 30 year old walkie talkie with no risk factors. I think you *are* being a bit overzealous, and are also opening yourself up to a lawsuit. I mean, using your reasoning you could also insist upon performing a perineal and vaginal exam, but it would be inappropriate. If I, as a healthy 34 year old, were in the hospital with some acute illness, I would be very suspicious of a nurse who insisted upon visualizing and touching my buttocks and perineum (unless I were in with a related issue). I would definately refuse, and probably complain to the hospital about it.

Perhaps you should ask for some clarification on what exactly is considered the standard of care of your hospital in regards to a complete assessment. By performing more than a standard assessment, you are actually putting yourself at risk. Plus, the admitting physician should perform a complete exam, and you can access that in the H&P. If there are no risk factors, and the H&P indicates that the skin is intact (or exam was deferred), then there is no reason for you to perform one.

Hope that helps. I'm glad you are so dedicated to your patients; but I agree with your coworkers that you need to tone it down a bit.

[beautifulb]

I agree with Ljds. I don't usually check walkie talkies bottom unless there is a reason to.

[suebird3]

It never hurts to check, though. Stranger things have happened. How many of us can see our back without using a mirror?

Suebird

[ChayaN]

Just remember that patients have a right to refuse an exam if they feel uncomfortable with it for whatever reason.

[ljds]

Originally Posted by suebird3

It never hurts to check, though. Stranger things have happened. How many of us can see our back without using a mirror?

Suebird

So you check every patient's bum with physical assessments?

I don't know, I guess I just think that is what my critical thinking skills are for--if there is ANY reason, then yes of course I will check. But we could spend all day discussing the what ifs. I don't do digital rectal exams on all my patients, even though they COULD be constipated, or have a hemrrhoid or enlarged prostate. I COULD do a breast exam on every patient who doesn't have a PCP, to ensure that they get one good breast exam in. I COULD do a complete ENT exam. I'm sure everyone once in a while I would catch something that might be initially missed. But I don't do these things routinely; rather, I use my critical thinking and my assessment skills to determine which patient would benefit from a more extensive, in depth assessment.

We COULD just do routine chest xrays and full body scans on everyone who walks in; we'd probably catch some things that might have been missed. But we don't, because it is a waste of time and money. You see what I mean?

I feel like checking *everyone's* bum is violating and simply unnecessary, and is more likely to cause problems (harassment lawsuit, patient's emotional discomfort and distrust of nursing staff) than be helpful.

Do YOU want your bum checked every 12 hours? Even if you are completely mobile, have no other health issues, have no perineal pain and are in for, say, pnuemonia?

[NurseyBaby'05]

Often I will simply ask a walkie/talkie if there's anything on their skin I need to know about. I specify scrapes, bumps, bruises, rashes, etc. Then I document what they say and whether or not they have allowed me to assess the said spot.

[jonear2]

Originally Posted by ljds

I work on an acute medical floor. I NEVER check the skin on someone's bum unless they are at risk for skin breakdown--incontinent, immobile, dependent edema, loss of sensation, or history of previous decub all comes to mind. I would NEVER check the skin of someone who is a 30 year old walkie talkie with no risk factors. I think you *are* being a bit overzealous, and are also opening yourself up to a lawsuit. I mean, using your reasoning you could also insist upon performing a perineal and vaginal exam, but it would be inappropriate. If I, as a healthy 34 year old, were in the hospital with some acute illness, I would be very suspicious of a nurse who insisted upon visualizing and touching my buttocks and perineum (unless I were in with a related issue). I would definately refuse, and probably complain to the hospital about it.

Perhaps you should ask for some clarification on what exactly is considered the standard of care of your hospital in regards to a complete assessment. By performing more than a standard assessment, you are actually putting yourself at risk. Plus, the admitting physician should perform a complete exam, and you can access that in the H&P. If there are no risk factors, and the H&P indicates that the skin is intact (or exam was deferred), then there is no reason for you to perform one.

Hope that helps. I'm glad you are so dedicated to your patients; but I agree with your coworkers that you need to tone it down a bit.

The thing is, full skin checks are a part of our routine assessment. In fact our facility has dubbed wednesday "butt check" day. The nurse manager from each floor goes around to do a full head to toe skin assessment on each patient to see if the nurses missed anything. I think it has something to do with a big lawsuit a couple years ago that had to do with undocumented skin breakdown. I am following P&P on this issue. The flowsheets even have a skin assessment section complete with the diagram of the body so that the nurse is free to draw pictures if words cannot describe. Any skin impairment from a scrape to a boil and beyond must be referred to wound care nursing for follow up.
I do not "enjoy" doing skin checks particularly and I was under the impression that every facility had the same attitude as mine. Doctors in the ED do not do skin checks and in fact the Wound Care team (nurses) have held many time consuming inservices about how you are never supposed to trust anyone else's documentation even the doctor's. I would not go to the H&P on admission to check the patients lung sounds even if he were admitted for say finger pain. I also do not equate looking and blanching someone's buttock with performing a digital rectal exam. If the patient refused the exam I certainly woud not push it, I would document the refusal. But I cannot document "skin intact" if I dont know that it is. I hope this clarifies the situation in that it is not me personally who just throws back the covers to see whats to see, but actually a facility wide policy which I am trying to follow. The original point of the post was that I was having a hard time doing the skin checks that I am supposed to do. Maybe this info will help and not make me sound so much like a perv.

[Sunflowerinsc]

How in the world would you have time to do that on a "walkie talkie"???

[beautifulb]

On a different note, many many times when I palpate pedal pulses the pt. will say to me "Nobody else does that".

It kind of does make you wonder what we all do in terms of pt. assessment.