I have a question about skin/wound assessment. My hospital uses Cerna for computer documentation and when doing integument assess. it asks if the skin is intact or not intact. This can be very obvious ulcers, open gaping wounds are “not intact” skin, and bruising, redness, and blemishes are “intact skin”. My question is when it comes to surgical wounds…. I have been putting “not intact” and adding a comment about it being a surgical incision/wound etc. Because technically a break in the skin is “impaired skin integrity”
The problem is that one nurse documents intact the other documents not intact and it just makes us look silly
Advice? Any good websites for concrete assessments?
Last edit by LSRNgrad2008 on Sep 25, '08
: Reason: more info
I just found this and I know you asked it several months ago, but the hospital I'm at uses cerna too and the nurses do the exact same thing you described. When going over preplans with our instructor, someone said that a pt with a surgical wound's skin was intact. The instructor said that skin cannot be considered intact if there is a surgical incision, or even if the patient has drains.
So I know exactly what you mean. All of us were so confused because in one column for a specific time it would say intact, and another column would said not intact, lol.