Butt Checks

ljds · May 18, 2006

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?

weetziebat · May 18, 2006

On the plus side of bum checks would be the possibility of detecting an unusual mole not known about by the patient. I worked with a nurse who died of malignant melanoma - it started as a small mole on her upper thigh/buttock and went undetected till too late.

But I'd do that at the initial admission assessment, not on a daily or Q shift basis.

psalm, RN · May 18, 2006

...new admits on the floor get a skin assessment. I ask if the pt has any bruises, scars, surgical scars, wounds not apparent with clothing on. This would cover genital wounds, be they surgical or from disease. We are to do a head-to-toe skin assessment on admit to the floor & every 7 days. Check between the toes!! And for wounds, get the camera out if necessary.

jonear2, RN · May 18, 2006

Umm, I never said anyone called me a perv, I was just making a joke, not getting defensive. Actually Im just as curious as you all about daily assessments. I hope that we will get alot of feedback on what assessments people are doing. I hope that this will serve as a learning tool for myself and others who, like me are still very very new.

My assessment includes

heart/lung/bowel sounds

When the pt rolls to the side for me to listen to lung sounds on their back thats when I check the skin- the gown is open anyway.

peripheral pulses radial and pedal

heels for breakdown wwhen checking the pedal

muscle strength and grasp (important for fall precautions)

And I do PERRLA because I have had a pt who was blind in one eye and I never would have known it had I not done that.

The whole assessment takes about 5-10 minutes at the most.

daisey_may · May 19, 2006

I think that a couple of people are taking this thread a little too personal.

I think that a "butt check" every 12 hours is a little excessive, but I think that the fright from a recent lawsuit is understandable, too. There is the issue of pride and dignity for the pts, but the biggest problem is if it gets in the way of nursing care. Time is problem from everyone and not everyone has the time to do a complete assessment every shift. When you describe it as a "butt check" to the pts, I can see how they would maybe give you a weird look. Also, it would seem strange that a skin assessment is done every shift, or is a complete assessment done, too? Skin assessments may not be so necessary on someone who can walk freely unless they were at an increased risk. A pt has the right to refuse such as check, of course, but time is such a touchy subject for nurses because there is so little of it. There is a question of the practicality of it, though. It's wonderful that you care so much for the patients, but I don't think the patients will be suffering or your floor will be at risk for another lawsuit if you cut back on the skin assessments who are not at an increased risk for skin breakdown.

Otherwise the assessments that I regularly do are on post-surgicals and they include wounds, drains, dressings, I&Os, vitals, flatus, catheters, voiding, pain, heart/lung/bowel sounds, and that's what I can think of off the top of my head.

But then again, post-surgicals are only in for a few days at the most usually, so they are greater risk for things like DVT and not things like skin breakdown from immobility.

Home Health Columnist / Guide · May 19, 2006

When I worked in the hospital and homecare, always asked ALL persons to sit up or turn over to assess posterior lung sounds, do quick visual assessment of "skin integrity" and straighten draw sheet/linens.

Found awful lot of trash: needle caps, alcohol wipes, piggyback tubing, old dressings that walkie talk patients never realized was there. If they declined, just documented the fact.

Don't get me started on nurses who NEVER took off patients socks/hospital slippers and what I'd find there on pedal pulse check!

dayplay · May 19, 2006

I'm glad I work in the Critical Care Unit where most of our patients only wear hospital gowns. When you ask them to turn on their side such as, line changes/positioning Q2hrs, listening for breathsounds/wiping their backs---whooalaaa...the butt is just right there...no need to ask...LOL

elthia · May 19, 2006

If they are in the gown I look at the backside when doing lung sounds, but I do not pull down underwear or boxers if it is a pedi or 20 through 50ish walkie talkie. I do I ask if they have any cuts/sores/wounds/scrapes/rashes especially if it is my first time with the pt, and then chart "pt denies any ----". I feel that that is sufficient. A 9 y/o in with abd pain does not want a stranger looking at their bum, neither does a 45 y/o ACS 3 walkie talkie, nevermind that that stranger is a nurse. I often use the Braden scale as my guide...if they score less than 17, I consider doing a head to toe skin, greater than 17, I defer the "nether regions".

Tweety, BSN, RN · May 19, 2006

Umm, I never said anyone called me a perv, I was just making a joke, not getting defensive. Actually Im just as curious as you all about daily assessments. I hope that we will get alot of feedback on what assessments people are doing. I hope that this will serve as a learning tool for myself and others who, like me are still very very new.
My assessment includes
heart/lung/bowel sounds
When the pt rolls to the side for me to listen to lung sounds on their back thats when I check the skin- the gown is open anyway.
peripheral pulses radial and pedal
heels for breakdown wwhen checking the pedal
muscle strength and grasp (important for fall precautions)
And I do PERRLA because I have had a pt who was blind in one eye and I never would have known it had I not done that.
The whole assessment takes about 5-10 minutes at the most.

Good assessment skills. Skin assessment is part of a good head-to-toe assessment and I incorporate that into my overall assessment, without specially asking "may I see your butt".

We are required to do Braden scales on all our patients. Those with a BS of less than 18 should have their butts checked q assessment. Walkie talkies don't need a specific butt check, but just an overall skin asssessment during their routine assessment or throughout the day.

A good assessment focuses closely on the needs of the specific patient to be focused on.

grinnurse, RN · May 19, 2006

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.

Amy-I agree with you on this subject. We have skin sheets for each patient and alot of the nurses that I work with will put down that the skin is intact on the walky talkies when in all actuality its not. As someone said in an earlier post, you can't see your back and the walkie talkies, are at risk for melanoma and your skin check may be the one time that something treatable is caught. Or God forbid, some kind of physical abuse. I also check my Peds skin too. There is a reason those skin sheets are being used. Of course if the patient refuses that is what I will chart but I also explain to the younger ones my reason for doing the skin check and then they understand why I am looking and haven't had one yet that has had a problem with it.

anniev · May 19, 2006

jonear2 come work LTC my DON would love you ! It is amazing the things not found on admisson usually a time situation.

Sean 91 · May 21, 2006

We are required to do a full skin assessment on all patients, including the backside....but we don't unless the person appears at risk. But occasionally you get the walkie-talkie elderly person who ambulates on own fine to the bathroom but spends amost of the time when in bed on his/her back though reminded to turn or invited to allow a pillow to be placed under hip. Nurses get written up at my facility for such matters if they miss them.

So I always tell the aide, "Let me know when you are going to turn (as in TQ2H, or clean the patient, and I'll help," then I jump in to complete the skin exam. Occasionally one finds a red coccyx that hasn't been previously charted, esp in transfers from ICU. And the latter is important if ICU hasn't charted it properly so my med-surg floor doesn't get blamed for the Stage I.