Why Full Skin Assessment Matters (every time!)
As nurses, we can all agree that time is precious.
Full skin assessments take time-and doing a thorough one on each and every patient definitely cuts into 100 other things on your to-do list…
But it is SO essential to protect your patient (and even your nursing license) from complications.
When you catch a skin issue early, you help your patients avoid unnecessary pain, suffering, infection, and worse. Wounds that go unnoticed until later can result in prolonged hospital stays, more involved interventions, and even legal troubles.
Let your patient know what to expect from your full skin assessment
If the patient is alert and oriented, a quick explanation will usually do. Let them know you need to take a quick look at their skin to check for any redness, rash, or wounds.
Most patients understand and are cooperative with the skin assessment once they’re settled in. And many have been through the hospital admission process enough times that they know the drill before you even ask.
How often to perform a skin assessment
If you’re anything like me, you’ll find yourself subconsciously doing nursing assessments on people who aren’t even your patients!
The more experience you get, the better you’ll become at assessing things like skin temperature, color, turgor, and moisture…even when you’re not doing a “formal” skin assessment.
For patients with a wound, it’s even more important to regularly monitor their skin. The frequency and level of documentation detail depends on your facility.
As a general rule of thumb, you should chart a basic assessment at every dressing change (and any other time you visualize the wound) and record measurements at least weekly.
Skin assessment barriers (or patient refusal)
Patient refusal should never be the default for things that might be tricky or uncomfortable.
That being said…
There may be situations where no matter how many attempts you make to assess or provide education, your patient just doesn’t budge. Or, your patient may have some immovable cast or reason they can’t be turned.
In these cases, it becomes out of your control, and unfortunately there’s just not much you can do.
If you’re unsure, use your charge nurse as a resource. Some difficult patients respond to the authority of a charge nurse explaining the “rules”. Plus, anytime you’re in doubt, it’s smart to get input from an experienced nurse who can help you with what steps to take next.
Of course, it’s important to respect a patient’s wishes. If a patient still refuses after all that-don’t force it. Your safety is just as important! And messing with a device you’re not allowed to remove isn’t good for you or your patient.
In this scenario, your new best friend is documentation.
And I mean really document-in extreme detail.
Include your multiple attempts, education provided, names and roles of any charge nurses or doctors you notified, and your patient’s response (use quotes whenever possible).
If the chart is ever reviewed later on, you want it to be clear that you did everything within reason. In the case of a physical barrier in the way, assess and chart on all areas you can see and describe why any area was omitted.
This way, if a patient does end up with a problem in an area you were not allowed or not able to assess, you will know you did everything in your power-and your documentation will reflect it.
This complete skin (and wound) assessment can seem a bit overwhelming. But as you get some practice, you’ll find it feels less scripted and even becomes second nature!
What’s the most challenging issue you’ve come across when trying to do a wound or skin check?
