Skin Integrity

[hkoreenrs]

As a registered nurse and clinical instructor I am always looking for best practice. I would like to pose a question to see if I can get some legal advice on how to chart on the specific topic of skin integrity. We have a computerized charting system. There is a section titled "skin integity" and the click-the-dot option I have to answer about skin integrity is intact, not intact, unable to assess. So the question is, when is the skin considered "intact" or "not intact"? Is the skin intact or not intact if an IV is present? Is the intact or not intact if an epidural is present? Is the skin intact or not intact with a chest tube or thoracotomy incision? Is the skin intact or not intact with a tracheostomy?

Would love to hear your feedback. If anyone has any evidence based practice articles I would love the links.

Sincerely,

HKoreenRS

[himilayaneyes]

I personally have never seen anyone chart that skin isn't intact b/c of something invasive placed by the hospital such as an IV line or chest tube, etc. If that were the case, no patients would have intact skin. The real question is does the patient have a decubitus or skin tears...for the most part we aren't looking for where the IV punctured the skin...that's a therapeutic intervention done by the hospital staff. Pt didn't come in with that hole we placed on their arm. If you really have questions, you could contact the risk management department of a hospital or a legal nurse consultant. More than likely they'll tell you to not get too technical...gives the lawyers in a malpractice suit more to play with in court.

[HamsterRN, ADN, RN]

In our system, we don't consider an IV insertion site or CT insertion site a wound because we chart on the condition of the insertion sites under the assessment of the IV or chest tube. Once a CT is D/C'd, then we consider it a wound a chart on it as a wound (drainage, erythema, etc). I suppose you could make the argument that an IV insertion site becomes a wound once it is D/C'd, although charting on that seems like a waste of time.

[leighannf]

personally i do consider the skin not intact if there has been anything inserted, as to me there is always the potential risk of infection with the introduction of any equipment.

[Forever Sunshine, ASN, RN]

I consider the skin not intact if there is a skin tear or pressure ulcer.

But in my nurses note I would document it like this

"Skin tear to L forearm" .. not "skin not intact". to me if you put that it leaves the reader wondering how its not intact

[merlee]

This is for unintentional issues, not interventional sites unless they become irritated or infected. Skin tears, pressure areas, decubiti are what you are looking for here.

[wound warrier]

As a wound care specialist, an IV ot CT tube insertion site is not considered not intact skin. If the pt experienced trauma, pressure ulcers, skin tears, etc., then the skin is deemed not intact. As HamsterRN noted, once a CT tube is removed, the area would then be a wound and charted as wound from chest tube insertion site. You do bring up an interresting point!!

[hkoreenrs]

Thank you wound warrier. I find our computerized documentation program to be a bit misleading at times. I always like to chat as though there is a lawyer looking over my shoulder. However, this subject get brought up over and over each semester when I teach.

[plumber1daniel]

Hi I have commencing the school of nursing, I am currently completing a wound skin tear on an elderly client. I am desparate for any help someone can give me to start off with my progress notes. I am not sure what obs to do and how to start progress notes. please help