Butt Checks

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 lady partsl 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.

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

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

Suebird

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

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?

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.

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 lady partsl 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.

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

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.

It seems to me then that, by having unrealistic expectations and protocols, your facility is setting itself up for more legal issues. How (and why) in the world do they expect you to perform complete head to toe skin assessments on every person, every shift? That is simply rediculous.

By the admitting physician, I mean the pt's physician who is in charge of their care during the hospitalization, not the ER physician. They should do a complete assessment of every patient, and document it on their H&P.

If I were a nurse at your facility, I wouldn't do complete skin checks on every patient, unless all of them were at risk. That is just stupid. I can't believe your nurse manager thinks this is a good idea, or believes that any of her nurses are following this. Instead they are just probably documenting it as "wnl" or "pt refuses" or whatever; and so the next time someone sues over it, they are going to get in even bigger trouble when it is shown that the hospital's documentation is unreliable. Then NONE of it will be believed in a court of law. What is your risk management thinking?!?!

And grow some thicker skin. I wasn't saying you were a perv. I was saying that I would be disturbed by a nurse who wanted to do a complete skin assessment on me, including my butt, if it wasn't warrented. I was trying to give you the pt's perspective. I've been hospitalized numerous times, and NEVER did anyone do a skin assessment of my butt, and I sure wouldn't have let them, either. There's little enough dignity and privacy in the hospital; I don't feel I should have to strip naked every shift change. I wonder how many pt's complain about it? Though, if none of the other nurses are doing it, then they probably aren't getting a good idea of how the pts feel about it.

In our facility we do our skin assessment on admit. to the floor. Take down all dressings, measure etc., etc., look for bruises, laceration ect., any skin breakdown ~A full body skin assessment. And that is noted on the admission paperwork. If there is a pt at risk, then that warrants continued assessments.

Hmm, this begs the question, what is considered a complete, routine shift assessment in your facility?

In mine you listen to heart, lungs and bowel sounds, palpate pedal pulses and homan's, assess for any edema, and assess cap refil. Pain, cough, nausea, vomitting, constipation, or diarrhea. Urine and BM quality and quantity, mobility, gait, and anything out of the ordinary -- skin breakdown, wounds, equipment and drains; of course anything that pretains to the care plan. I'm sure I'm missing something off the top of my head, but that's it in a nutshell. It takes about two minutes (or longer, depending upon how talkative and complex the pt is, and whether you've had them the shift before or not).

Things I *don't* do on every single routine assessment:

neuro check

palpate for neck, breast, abdominal or genital masses or for bladder distention

complete ROM of all major joints

palpate for CVA tenderness

check bums (or any other body part) for skin breakdown or lesions

check ears, eyes, nose, and throat

check reflexes

check cranial nerves

What about you all?