Butt Checks

[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?

[Spidey's mom, ADN, BSN, RN]

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.

Good post, as was jonear2's . . . . you don't need to say "let me look at your bum" . .. to do a skin check.

When we go in at 4 a.m. for first vitals, I check the back as I do lung sounds and then the patient gets up oob to the stand-up scale and I am able to check the rest of the skin. Obviously I'm not doing pelvic checks but I do ask if they have any problems.

We can do alot by not even telling the patient we are doing it during routine care in the morning. It is like counting respirations when they don't realize you are counting them because when they realize it, they breath differently.

I check pedal pulses and heels too for skin breakdown or mushiness.

steph

[ginampls]

Good for you for checking bums on everyone! I work on an oncology med/surg floor and even the walkie-talkies are at risk due to their compromised sytems! And thank you for taking the time to assess your patients!

[Chaya, ASN, RN]

We have to fill out preprinted assessment forms that have a section for skin assessment. Woe betide you if you leave a section blank! I'm diligent about a detailed check on initial admission assessment; at this time I ask the pt how active they were before being hospitalized and explain the need for the check. It's a quick visual check if they were ambulatory and if they are alert/ oriented I'll ask if they have any skin issues before I look. If they've been immobile I check back of head, elbows, heels, again explaining why.

Our daily assessment form also has a skin assessment section. I do refer to assessments from previous shifts/ days; if no skin issues noted and the pt is ambulatory and continent I will kind of limit it to what I can see while listening to lung sound on their back.

[PhoenixGirl]

Do you have aides that help with pts bathing and ADLs? I had a walkie talkie the other day, out of 7 pts she was the only one. So no, I didn't turn her to check her backside. And she changes positions herself as needed, so she wasn't ordered as a q2turn. But I work with great techs/CNAs who I ask "if you see anything unusual, such as breakdown or skin tears during showering, pls let me know." Then I'll go in to assess it. Other than that, with a walkie talkie that's not at risk for breakdown, and not ordered any creams or xenaderm for their bottom, I don't check. If they have their own BRPs I just ask them "did you have a bowel movement today? Let me know if you need any assistance during this time." Then if they do, I can go in and assess without letting them know exactly what I'm looking for.

HTH

Rebecca

[CRNAorBust]

In my mind and on my floor we are told we have to assess the WHOLE patient especially if they're new to the floor. If the nurse who took the patient initially didn't find anything then we're cleared to not to have to look. But if YOU"RE the one taking the transfer or new admit. You better look or it something may come back to bite you later. What happens if they had a fall and decided not to say anything till they get out and home? Did anyone look when that patient came in to see if they had any bruising etc? And how often do you have a patient who has psych issues but that's isn't on the chart or new admit report?

I think some of this is an issue when you LOOK young as a nurse. You may not inspire confidence in the patient. People often see me as a doctor so they tend to go with the flow when i ask them to do something. If that's the real issue you'll have to make sure you're following protocol on your floor. Then if the patient refuses you can either just document they refused OR ask them if they would like another nurse (or even the charge nurse) to come and look for you. I had a mentally altered elderly man refuse meds because he thought i was going to feed him green horse poison. I asked him if wanted to speak to someone about that. He did. So i got my mentor there and she and i made sure he understood i was there to help. He then took the meds. So you have to handle it according to the rules of your hospital and when necessary you get a more experienced nurse to come in and help.

[lpnstudentin2010, LPN]

.....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 am not sure how, as a patient I would feel with this. Someone who is NOT my nurse examining me so intimately to check if they are doing their job. You at least have a bit of a relationship with your nurse. You have none with the nurse manager.

[UM Review RN, ASN, RN]

I do skin checks on everyone. It helps to wear gloves, I've found. If I find anything they might not be able to see, I ask how long they've had it.

On walkie-talkies, to assess for abuse and skin conditions that they may not be aware of. A couple of times I've found enormous bruises on these folks from a recent admission with recent Lovenox use. Obese people have a tendency to have fungal rashes in skin folds that they're unaware of. On elders, to assess for redness, potential breakdown, evidence of falls, evidence of Coumadin or steroid use, and recent skin cancer removals (they always forget to tell me about those).

Usually our W-T's use the hospital gowns so I can just take a discreet look, but if I need to take things off, I explain that I need to briefly look at the skin, and they usually comply.

[ShannonSRN]

O.k. this is a very interesting thread. I would like to make a small point...

Medicare is no longer paying hospitals for "Never Events" (conditions acquired in the hospital) including: Skin breakdown, foley catheter related UTI's, surgical infections-mediastinitis, and wrong site surgeries. Medicare have also recognized other non-reimbursement eligible injuries that are going to be brought over a couple of years including: DVT's, etc. ALL of the commercial insurance companies are jumping on board!!!!!

So not checking for skin conditions on 'walkie talkies' is absolutely going to cost all of us in the future. Actually performing a FULL head-to-toe each shift and charting your findings are going to CYA later. Eventually if documentation and assessments do not improve, we will find the changes reflected in our paychecks. Facilities will not be able to pay US if they are NOT getting paid.

O.K. off my soap box....

[litbitblack, ASN, RN]

I was just going to say that about the new medicare thing. Now my facility is requireing and enforcing the remove a dressing unless there is a specific order not to on new admits. It doesn't take much to check the back and bottom and it is part of our assessment. Young or not the skin needs to be checked to take care of potential problems and to cya. IT will fall back to the nurse eventually when the facility doesn't want to pay for the wounds not documented on admission....