skin tear charting

Jillybean48 · Jun 15, 2014

You are going to need to chart how and when you became aware of the skin tear, if the pt can speak you need to ask him/her the circumstances leading to the skin tear and to rate the pain on a pain scale level of 1-10 and chart what the pt says with quotes like this (just as an example): Pt. states "I was transferring myself from my wheelchair to my bed when my leg hit the table and then I felt the pain and I called the nurse". You need to assess the wound by measuring it; sometimes it's just a straight line but sometimes the wound is an uneven tear and your measurments may say something like this "2cm horizontal by 3.5cm vertical". Also say whether or not wound is well approximated, can the two sides be pulled back together easily or is there skin missing? Say what you did to treat the wound. Did you cleanse it with normal saline? Are there any signs/symptoms of infection on assessment? Chart the vital signs. Did you steri strip the two sides together and did they come together cleanly? Did you cover it with a 4X4? YES you have to call the doctor. Not only do you have to notify him because it is an injury but you also need treatment orders. Some facilities have standing orders and the doctor may not want to be called until office hours, I don't know what your facility prefers. Either way you will need to be writing some kind of treatment order for this wound. YES you need to call a family member or whoever is responsible for this patient because this is an injury. On a sidenote: I have worked geriatrics and pediatrics for 17 years and in these 2 cases we always have to notify a responsible party, I do not know what kind of nursing you are in so if this is some kind of case where this is an adult of age who is responsible for him or herself I don't know about calling a family member about a skin tear..... that would be a new one for me, I can only speak of my own experience. Also, all of the phone calls you make will need to be charted also. An incident report will need to be filled out. You DO NOT chart that filled out an incident report, that is not part of the chart. I would suggest you notify your nursing supervisor of this skin tear and ask her what she wants you to do about alerting the doctor on a Saturday evening (it's Saturday eve where I am, not sure about you), some places want you to call the doctor immediately some do not; either way, that is what the supervisor is there for, she can answer that question for you and once you find out you will know and you'll never have to ask her again so if she gets mad about you calling her.... well that's just too bad... you have to do what you have to do to cover your butt and your license.

amoLucia · Jun 15, 2014

Sometimes a skin tear/wound is 'of unknown origin'. Pt can't tell you how. Or an injury may have occurred when care was being provided by another caregiver. That has to be worded into your documentation. Also record any comments to you by any visitor/family/other pt. And if another employee was involved, they may have to fill out statement of their own re the occurrence.

Always follow your facility's P&P for such injuries. And you probably have to do q shift charting for some duration per P&P.

Just a reminder - if you need to reference another pt in the injured pt's chart, HIPAA applies. Check with your facility how they want you to chart it. You can't put Mary Smith's name in Sue Jones' chart.

ALWAYS, ALWAYS notify family of such incidents. YOU DO NOT want them to come in for a visit and be surprised seeing a big kerlix/king on their MOM's shin. Makes them suspicious!

And if on 11-7, I still make sure I do the calls, usually right before I leave. Personally, I don't like leaving the calls to chance if next shift forgets or is delayed.

colorsofthewind · Jun 27, 2015

Hello, what would you include in a incident report if your unsure how a resident received a skin tear and resident can't tell you how, yet your told you have to give a detailed reason?

jojo489 · Jun 30, 2015

OP, in addition to the above, also include interventions to prevent the same thing from happening again. Example, if resident got up and bumped knee on table, maybe position table differently or if skin is frail and easily torn, to apply Geri sleeves or something.

To previous poster, when it's an unknown I just chart that patient was last seen by CNA sitting in chair at whatever time and then at whatever time the skin tear was noted by whoever, whether the patient was assisted to transfer recently, check wheelchair and bed frame for sharp edges and document that, and that the patient is unsure how they go what they have.