Skin assessments documentation

Specialties Geriatric

Published

I am applying to another nursing home job and I really struggle with skin assessments. I know I am over-complicating things, but I have a very hard time with what everything is (terminology). I did no rotations in a nursing home during school and honestly had little experience with the elderly population and now I am struggling with this. The first time I did a skin assessment I was in an absolute panic as to how to fill out the paper. I saw spots all up and down the arm (and at the time didn't even realize they were age spots). There was a little scratch with some skin peeling and I wasn't sure how to document that? I put small skin tear, but I don't think that is a skin tear. I don't know if you label age spots on a skin assessment or not? I mean I get you need to document everything, but getting how to word things. Would "Multiple age spots bilaterally on upper extremities" be appropriate?

I wish I could find a book that had pictures of people and examples of documentation. Anyone got any resources for this? Tips for me not over-complicating things?

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And I realized I asked a similar question a while back, but what would be helpful would be some examples of your wordings on this. I'm really trying not to be annoying with my questions.

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Specializes in critical care, ER,ICU, CVSURG, CCU.

There are some good programs sponsored by wound care companies that supply supplies to your facility...they usually have a nurse manufacture consultant that I have found most informative.....most DON should be a go to resource....also your companies regional nurse consultant.

there are several skin resource books, DVDs etc on Amazon.com

the basics involve assessment, and discovery documentation,

coordinating with provider and facility a treatment plan, to resolve and minimize reoccurrence.

then usually weekly monitoring of treatment plans effectiveness....? does it need to be changed?

it is so very important to document comprehensive accurate skin assessment on admission, and transfer from other facilities.....very important to define was it existing, or facility acquired.....before long with continued effort you will be a pro!

best wishes

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there are several skin resource books, DVDs etc on Amazon.com

Do you have any names? Particularly interested in the dvds, but books would help too. I did look on Amazon, but was having trouble figuring out what to search for there.

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Specializes in Pediatric.

I think one of the best things you can do is just describe what you see. Usually after this initial assessment, someone follows up and verifies/checks it. At least where I work.

If I'm unsure on something I just grab a coworker. (For example, "Hey Nurse Jane, do you think this is a DTI or a diabetic foot ulcer?"

All you can really do is your best. :)

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Specializes in Psych, Addictions, SOL (Student of Life).
Do you have any names? Particularly interested in the dvds, but books would help too. I did look on Amazon, but was having trouble figuring out what to search for there.

On Amazon or google search for wound assessment/Wound classification/skin integrity always add + Images. Also CE classes in wound classification might be a good choice. I like doing skin and wound assessments is it, a pressure wound, Deep Tissue Injury, Venous or arterial wound, Stage I, II, III or IV? Is the slough or granulation love it love I love it.

Treating them is even more fun. I got to play with the maggots last week :)

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Specializes in Psych, Addictions, SOL (Student of Life).
I think one of the best things you can do is just describe what you see. Usually after this initial assessment, someone follows up and verifies/checks it. At least where I work.

If I'm unsure on something I just grab a coworker. (For example, "Hey Nurse Jane, do you think this is a DTI or a diabetic foot ulcer?"

All you can really do is your best. :)

Yes most facilities have a designated wound person because facility acquired wounds can cause facilities to lose Medicare dollars.

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Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

Old age spots can be stated as Pigmentation changes, same as the darkened lower legs of obese patients that have had multiple problems with foot/ankle/lower leg cellulitis in the past. Skin tears are trauma related, like banging against something. You know what rashes and petichia look like. Wounds/tears can be just a removal of the top layer of skin, that would be partial thickness. Look at the skin and chart what you see (not every mole, freckle). Measure any wounds/tears and see if the areas appear infected so wound care orders can be initiated. Chart bruising and scabbing. Soon you'll be a able to do a skin assessment quickly. Be sure to check the groin and under the pannus for redness/yeast and the bottom for any issue there such as redness or wounds. Check diabetic feet carefully, and make sure to see the heels.

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Old age spots can be stated as Pigmentation changes same as the darkened lower legs of obese patients that have had multiple problems with foot/ankle/lower leg cellulitis in the past. Skin tears are trauma related, like banging against something. You know what rashes and petichia look like. Wounds/tears can be just a removal of the top layer of skin, that would be partial thickness. Look at the skin and chart what you see (not every mole, freckle). Measure any wounds/tears and see if the areas appear infected so wound care orders can be initiated. Chart bruising and scabbing. Soon you'll be a able to do a skin assessment quickly. Be sure to check the groin and under the pannus for redness/yeast and the bottom for any issue there such as redness or wounds. Check diabetic feet carefully, and make sure to see the heels.[/quote']

I think I've been over-complicating things. Thanks!

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