OASIS Alert

Published on Fri Aug 26, 2011 PDF

Documenting your patient's skin status helps paint an accurate picture of the care your agency provides. Keep three major areas in mind to be certain you're not missing a hidden threat to your patient's health and your agency's reimbursement.

1. Look your patient's skin over. The first part of doing a pressure ulcer risk and skin assessment is to do a visual inspection, says Dorothy Doughty, MN, RN, CWOCN, FAAN, director of the Wound Ostomy Continence Nursing Education Center at Emory University in Atlanta. Be sure to turn the patient over and inspect all bony prominences.

That means taking off T.E.D. anti-embolism stockings. "If you don't take them off, you don't see the heel," Doughty says. And even if the patient is all settled in and comfy, you must have them get up so you can complete the assessment. Otherwise, you could be missing a problem.

You'll also need to remove any dressings you can. "So often, I'll see the note 'duoderm intact,'" Doughty says. If you don't remove the dressing, you don't know what's under it, she cautions.

2. Use palpation as needed. For patients with light or medium skin, you can use your eyes to see color changes and open wounds. But with dark skin, you'll need to use palpatory findings, Doughty says. Use touch to assess changes in skin temperature and consistency. Look for fluctuant, squishy, indurated, or tender areas, she says.

Bottom line: You can't rely on visuals with dark skin.

3. Look for signs of impending and threatened ulceration. A pressure ulcer doesn't start out as an open wound, Doughty says. Remember to look for color changes or changes in skin consistency that indicate something is going on underneath. Signs that there is some level of tissue damage can include non-blanching, persistent erythema, or inflammatory response.

Tip: If you come into the home and your patient is on her right side watching television, you can check her back, left side, and heels right away, Doughty says. But when you turn her over off of her right side, there will be redness and warmth, so you can't immediately assess this area of her skin. Go on with other assessment items and then finish your skin assessment after she has been off her right side for 30-40 minutes, she suggests.