skin tear packets

quiltynurse56, LPN, LVN · Dec 14, 2015

We have separate forms for each. We must measure it and put that on the sheets along with how it looks. We need to try and determine how it happened as well. We need to figure out an intervention to prevent further problems as well as treat the tear. Let the DON know, call or fax the Doctor (we usually send a fax} and ask for further instructions if any needed. We also call the family.

When found at the end of the shift, the nurse who found and assessed it stays past to complete the paperwork. For me, change of shift is 10 p.m. and I usually save the phone call for the morning as by the time I get everything assessed and documented, I am not going to call family for a non-emergency at that time of night. Oh, we also document everything in the Nurses Notes.

We then make sure the DON gets the forms.

We have skin investigation sheets for non-pressure sores, pressure sores and for tears, cuts, etc. So the makes 3 sheets.

CoffeeRTC, BSN, RN · Dec 14, 2015

So, that would be an incident report, place on 24hr report, place on alert charting list for 3 days (all incidents get 3 days), would need a non presure ulcer skin sheet (measurements and location), would need to get order for treatment (call doc), call family and then a nurses note.

If it is change of shift, I would want the person that found it to at least do the incident report...if they saw what happend. I would take care of the rest.

So, were you dumped on by the last shift?

delia94 · Dec 15, 2015

No just keep finding them on my shift (11-7) and wanting to know how many other facilities have the same redundant paperwork.

CoffeeRTC, BSN, RN · Dec 16, 2015

We also do an investigation as part of the incident. Each person on that shift that may have come into contact will need to do a statement.

wanderlustnurse88, RN · Dec 16, 2015

Do you guys not have standing orders for wound care? More for the skin tears, to cleanse and cover using nursing judgment. We definitely do not have to call the doctor for a simple skin tear or bruise. If it is an ulcer or difficult wound, the MD will look at it during weekly rounds.

bluegeegoo2, LPN · Dec 16, 2015

I have 1 sheet (a triplicate copy) to fill out basic info like who/what/when/where/how. A note goes in the MD book. (They do daily rounds M-F) call family. Chart in eMAR. We initiate our own tx's and add them to eTAR, and put in on the 24 hr report. We chart for 3 shifts and it's done. Once it's healed, we have to "close out" the report and it goes to the DON for tracking. Management handles care plans, interventions, etc. It literally takes less than 5 minutes to process a skin tear as far as paperwork goes.

nurseredd · Dec 18, 2015

5 minutes to process skin tear paperwork? Can I work where you work please?! Haha

IowaKaren · Dec 18, 2015

No just keep finding them on my shift (11-7) and wanting to know how many other facilities have the same redundant paperwork.

That seems to be the norm for overnights. Find a good sized, dark purple bruise that you have to figure out how they got it, when they got it, what they were doing, etc. at 2300 (an hour into shift). And you HAVE to get it figured out. Period. I almost feel like changing careers sometimes because of it, just because of my integrity. I certainly don't get any other suggestions from upper management. Of course everything is found on night shift.