Conducting A Comprehensive Skin Assessment: AHRQ Preventing Pressure Ulcers In Hospitals Toolkit

Welcome. This webinar is going to be talking about conducting a comprehensive skin assessment. I’m Dr. Karen Zulkowski from Montana State University. Skin is your largest organ of your body.

It contains up to 15 feet of blood vessels in one square inch. It’s also the most visible organ of your body, and is the one that we can see if there are any irregularities in it. A little about me — I’m an Associate Professor at Montana State University. I’m also the Executive Editor for the Journal of the World Council of Enterostomal Therapists and the Editor of the 2014 International Ostomy Guidelines.

I’m a member of the Editorial Board for Ostomy Wound Management and Advances in Skin and Wound Care. I also am a legal consultant and a former NPUAP Board member. In addition, I still do wound rounds, wound dressings, wound care, wound care planning, once a month at a nursing facility. In this webinar, we’re going to talk about a comprehensive skin assessment: what are the attributes of it, how do you do it, how it’s a separate process from risk assessment, how we integrate it into our normal workflow, how we document and report the results, improving the process on the units, and how we integrate it into care planning.

We’re going to revisit in depth skin assessment topics. So please keep a list of any questions you have so your QI Specialist can follow up with you to address them. There are both attributes of a comprehensive skin assessment as well as goals of a comprehensive skin assessment. When we conduct a skin assessment, it’s really head to toe.

A skin assessment is more than just looking at the skin. You’ve got to touch the skin; you’ve got to touch the head, the back, every area of the body to understand what you’re feeling as well as what you’re seeing. The reason we do this is to identify pressure ulcers, but we also need to find out what else is going on. Is there dry skin? Are there areas of moisture damage? Do we see any irritation, rashes, raised moles, or risk factors, such as scar tissue, that may predispose the person to developing a pressure ulcer? It’s important to note that a pressure ulcer that’s healed will not tolerate the effects of pressure as well as normal skin.

Any time there’s a full depth wound in skin, it will only heal to about 70% to 80% of its former tensile strength. It also takes up to a year for the skin to completely heal underneath. Therefore, you have a scar that looks healed but really isn’t down deep, and it will open up much quicker. And this is really important in terms of planning your care.

We need to look at other skin conditions the person has. For example, if they have vascular issues, vascular wounds, if they have had any heart conditions, carotid endarterectomies. If you have large vessel blockages, you’re going to have small vessel blockages. And those are going to affect the skin all over the body.

We need to understand what kind of data we use to calculate incidents and prevalence for pressure ulcer rates. And we also need to understand that a skin assessment helps stratify risk. In other words, regardless of what their skin assessment score is, patients that have a current pressure ulcer are automatically at high risk for developing more pressure ulcers. And then as we identify the needs of the patient, we can incorporate that into care planning.

We need to look at staff issues. There needs to be a standard protocol in place, in your facility and on each unit, for a comprehensive skin assessment. Staff needs to understand the parameters of that skin assessment. And they also need to know what are some of the special issues for our bariatric patients.

However, the first thing you need to do when you’re actually doing the skin assessment is to explain to the patient and family what you’re doing — that you’re looking at the entire skin, what we’re looking for at the skin, and why this is so important. Frequently, we miss this step; and it’s important to the family and patients to understand that this is part of the good care that they are receiving at your facility. If we find something anywhere on the skin, we need to tell the patient and family about it. The assessment always needs to be done in a private space.

Use curtains, close the door, make sure no one comes in, in the middle — just walks in while you have the patient exposed. The patient also needs to be comfortable. We need to address pain issues. We need to know what we’re going to need to actually conduct this assessment.

But before we touch the patient, we need to wash and sanitize our hands. Then we need to put gloves on; and if they become soiled, we need to change them. If they don’t become soiled, you don’t need to change your gloves during the head to toe assessment. We also want to minimize exposure of body parts.

Now, when a patient has a gown on, we can take one arm out to look at the abdomen and chest and put the gown back on, and then pull the covers down to do the legs. But in some of our older patients, they’re very cold. So you might want to take in an extra sheet, bath blanket, towel — something that when we’re pulling the covers down, we can actually cover their torso to provide a little bit more warmth. We need to know if we are going to need help in turning the patient.

And we should have made arrangements to have someone in the room to help us. Stopping in the middle to get help to turn the patient over is very time consuming, as well as very disruptive to the patient. You need to know your facility’s policies and procedure in terms of head to toe assessment: who can document, how often should it be done? All staff needs to be trained to pay special attention around any devices for comprehensive stockings. Often patients come in, and especially our older patients or anyone with limited mobility, and we send them home with compression stockings.

But when they try to put them on themselves, they either twist them or they decide it’s too hard and have never taken them off. This can end up doing a great deal of damage. Patients that are really restless can move their tubing around or twist stockings or heel boots and actually end up causing more damage. Bony prominences, including the back of the head as well as the heel and sacrum, are frequently the areas where a pressure ulcer develops.

All staff needs to know to pay particular attention to these areas when they’re doing anything with the patient. Skin to skin areas — a patient laying on their side, for example, that has one leg on top of the other or the penis. And if the man has a condom catheter, this is critical that it’s checked at least daily. There have been some horrendous pressure woundss develop on people’s penis as a result of these catheters.

Look at the back of the knees. Look under the leg. Are they laying there with their legs crossed, for example? Inner thighs, especially in our very large people, or between skinfolds and always between the buttocks. And know what your lighting is like in the room.

Sometimes to actually visualize some of these areas well, we need to bring in a flashing to provide adequate lighting to really see the color of the skin. We need to look at any area where the patient lacks sensation to feel pain, such as the bottom of the feet in our diabetic patients who have neuropathy. But it’s also important to note that more than just diabetic patients can develop neuropathy. And some of our older people can’t feel well either.

We need to really look at areas that have had a breakdown previously because, like I told you, these are very susceptible to future breakdowns. Look at the medications. If the patient has had an epidural, they can’t feel. Pain medications and sedatives limit the patient’s ability to feel the need to turn or shift their body weight, and so we have to do it for them.

And this can be even in some of our healthier people. It can also be in younger people who aren’t moving because of fear; they’re afraid to move. For example, I had a young woman who worked with me for a while who required open heart surgery. She was in high school.

No one explained to her that she needed to move. And she told me how afraid she was and how bad her back and heels hurt because she didn’t move. She said she was afraid if she moved, she would disrupt any of the tubes and die. Yet no one talked to her about this.

Interestingly enough, she was in premed when she started college because of her experience and wanting to make a difference. So it’s important, regardless of the age, that we address these issues with our patients. When we’re conducting a skin assessment, we need to look at temperature; turgor or firmness/softness of the skin; the color of the skin; the moisture level — dry, oily, moist; and the skin integrity. Are there open areas? Is it intact? Are there rashes? What are you seeing? And not only do all these areas need to be assessed, but we need to document them; and we need to teach the staff about them.

To look at skin temperature, you have to touch the skin. Is it warmer or colder than surrounding areas? We frequently see this in patients with wounds. If we feel around the wound, it can feel really hot or it can feel really cold. And this can indicate skin damage, especially a Stage I pressure ulcer or deep tissue injury.

In both of those, these are very hard to see on darkly pigmented skin. So we have to pay particular attention to the skin temperature and colors in this darkly pigmented skin. Sometimes it can indicate a pre-ulceration in the diabetic’s foot. But it also can indicate an area of inflammation or infection in any part of the body.

Skin turgor is very easy to measure. And certainly nurses’ aides and everyone on the team should know how to do this. Normally, your skin returns to its original state. When we stretch it up, it goes right back to where it was.

So we want to try tenting the skin, and one of the best places to do this is on the back of the hand. Pinch your skin up. If your skin is healthy, it will sometimes be very difficult to pinch. That means it’s healthy and you’re not dehydrated.

If you can pull it up and it stays up, the person is dehydrated. This also tells you whether the epidermis and the dermis, the outer layer of skin and the inner layer of skin, are attached. In other words, if you pull it up, it’s really easy to pull up even if it goes right back down. It can be that the skin is no longer attached, and these people are going to be much more susceptible to skin tears.

So the simple act of looking at the skin — tenting it, pinching it — can tell us a lot about the patient. If it’s very stiff, it could be the area of a scar. The skin color — we’ll look at different or adjacent areas for skin color. Compare leg to leg, arm to arm.

Does one area, such as the left leg, look much more red or purple or discolored than the right leg? Does one arm have bruising on it? Is the rash you see on the buttocks symmetrical? If you’re seeing bruises all over the body, is the person on anticoagulants that could be causing the bruising? Have they fallen and not told anyone about it, or is there elder or spousal abuse going on? Redness can indicate many skin problems. It could be a pressure ulcer. It can be a rash. It can be infection or cellulitis.

And it’s important to note what these are, so we can do our care planning that’s appropriate for the patient’s needs. Deficiencies can also affect the skin. We can have a Vitamin C deficiency, which causes purplish splotches on lightly traumatized areas. Zinc deficiencies can cause redness of the nasal labial fold and eyebrows.

Skin color, this is especially important if we’re looking for a Stage I pressure ulcer. When you push on a reddened area, if it turns white, that mean that it’s blanchable; and it’s not a pressure ulcer. If it does not turn white, it’s non-blanchable and would be a Stage I pressure ulcer. Keep in mind that areas of redness that have been caused by pressure, even if they’re blanchable, take a long time to go away — in fact, three times as long as you had the pressure on.

So in other words, if you cross your legs and you look underneath your top leg after a little while at your skin and it’s red and you push on it and it turns white, that means it will return to normal. But if that pressure was on for 15 minutes, it can take up to 45 minutes for that redness to go away. If it’s taking too long, you really need to worry about the blood flow to that area and understand that it would be a very high risk. We need to look at purple or bruised-looking skin.

What’s causing it? Is it a deep-tissue injury, was there pressure involved, was it simply from a fall, or is it something else? Paper thin skin in people that are taking any prednisone or non-steroidal medication, we need to look at older people or sun damaged areas. And these are usually the people that are at very high risk for skin tears. We need to be planning care to prevent the skin tears and also teaching the people how to prevent them when they go home. Remember, darkly pigmented skin does not blanch; and that’s why it’s so difficult to pick up Stage I pressure ulcers in our darkly pigmented skin.

We need to look at skin color. Does the color vary greatly from one area of the body to the other? Is there reddened skin on the sacral or buttocks? It can be from a variety of causes. And you’ll need to get the ideology correct so you can treat it appropriately. If you have moisture damage, you need to put creams on to prevent moisture from getting to the skin.

But if that reddened area is a pressure ulcer, those creams aren’t going to do any good; or vice versa. So we need to know the cause so we can apply the appropriate care to that cause. Oftentimes when we have moisture, we can have some areas of pressure. And that’s why it’s critical for you to identify it so you can know how to treat it or what you want to treat first.

Our moisture-associated skin damage can be dry or wet. And if you look at this picture, it’s actually a colostomy that we couldn’t get — it had so much coming out of it that we couldn’t get it dry enough to actually apply the pouch over top of it. So we put a catheter in to slow it down so we could get it cleaned up and actually get something to stick. And what was happening was the pouch kept coming off, and the moisture was getting underneath the wafer and causing the skin damage.

She had extensive maceration damage. That damage can be under skinfolds or between the legs or behind the knees. And so this is what can also occur in areas of high moisture in our bariatric patients. Ideology of moisture-associated skin damage can obviously be due to incontinence — urine alone, stool, both.

It can also occur because of wound exudate. That exudate is coming out of the wound. It’s running someplace out of the dressing or under the dressing in skin that hasn’t been protected. It can be from perspiration.

You know the saying that people have about your fever broke and you start perspiring? Well, people that are running a fever, it’s really true, can end up perspiring a lot; and the areas get really moist. Again, those moisture-prone areas that this occurs — in the skinfold, under the breasts, in the groin — can be quite extensive and lead to a lot of damage. We always need to look between the skinfolds in our bariatric patients, and that is often where you need the flashlight to really be able to visual well. There are products you can use to help keep the area dry.

But because these stay so moist, it’s often an area where we have either an infection or a fungal infection going on. Look around ostomies or a fistula that leaks. People that have developed trauma to their abdominal wall or that have Crohn’s can often develop spontaneous fistulas to the skin surface. And these are very difficult to keep the area dry and clean.

So know the ideology of the moisture so you can treat it appropriately. Look at the integrity of the skin. It should be intact. And if it is intact, that needs to be documented.

Because when you’re going through reviewing the records, it’s very disconcerting when you find intact, warm and dry, clean, clear, et cetera, and all of a sudden you have a Stage III pressure ulcer. Or you see that you had an area of redness, the next two days are no issues, and then the third day you have a Stage III pressure ulcer. Either someone wasn’t assessing adequately, was just copying page to page to make it look like the assessment was done, or you had a sudden pressure ulcer that developed that could be a Kennedy terminal ulcer or related to skin changes at life’s end. If your skin is not intact, identify the cause of the problem.

Was it pressure? Was it peripheral vascular disease, either venous or arterial? Was it neuropathic or diabetic? And it can be a combination of those factors. So you can have a foot with multiple wounds on it, and it can be a combination of pressure along with poor vascular status related to diabetes. We can have skin tears, especially in the forearms of our older adults. And we need to then look at that and how are we going to prevent them.

What caused them? It can be trauma-related. In our older patients, we see them falling; and they can suffer extensive trauma or accident victims. So we need to know the ideology so we can treat it and plan care. Do we need to turn them more frequently? Do we need to keep them off this area? Do we need a specialty bed? Do we need a dressing? In our bariatric patients, we need to look between the skinfolds; and these skinfolds can be very excessive.

I talked about having someone come in to help turn the patient; but in reality, we might need to have that person come in and actually help us move the skinfold. And we need to do this in a way that maintains the dignity of the patient. So asking the person to come in at the beginning to help you, and then have them step in and say, help me her, help me here, is a lot less traumatic for the patient than you get to their abdomen and say, oh my gosh I need help. I can’t adequately visualize this.

That’s where the planning ahead for needing help certainly comes in. It’s very difficult to sometimes see between the upper thighs and between some of these skinfolds. So even if you have someone simply holding the flashlight and telling the patient you need this to really visualize well because the lighting in the room isn’t adequate maintains their dignity. We need to look for rashes and macerations because these areas frequently have moisture damage.

We need to look at whether there’s bacterial or fungal infections going on, and we need to look for skin breakdown. We also need to make sure that the staff is aware that we might be putting creams in these areas to treat a fungal infection — what cream is being used, where it’s being used — for any kind of moisture issues in any patient. I often go into rooms and I’ll find four different kinds of barrier creams being used. What happens is as the level of risk changes or the need changes; they bring something else in.

But then no one knows which one is currently being used. We need to remove the old creams that aren’t being used. We need to put a sticker or identify some way which is the appropriate cream or which cream goes where because otherwise, we’re not going to have consistency in our planning or our care treatment. We need to look carefully at the perineum of the bariatric patient.

Often this is an area, again, that we can find dermatitis or we can find a fungal infection. I also find things like hair follicles or sebaceous glands that are blocked, and the person develops a pustule or nodule in the area. And we need to look at what the cause is because frequently these are then documented as a pressure ulcer when, in fact, they aren’t. We need to look carefully at the extremities.

In bariatric patients, there are frequently vascular changes. There can be edema and lymphedema. Really compare one side to the other and see if one is more edematous or is more swollen or has more exudate from the lymphedema than the other side. This causes a lot of tissue damage.

Consider the skin assessment as a separate process. It is not the risk assessment. You have to combine the two to adequately plan care. Skin assessments have to be a special focus of all the staff.

Nurses’ aides need to understand how what they’re doing ties into the care planning because it’s frequently the CNA that finds the skin issue or notices the skin changes because they’re the one in there with the patient helping with the bathing, changing them, cleaning them, changing their linen. So it’s important for them, and anyone on the staff, to understand the need to keep this a special focus. As people either improve or worsen in their medical condition, they change units. You need to always know what their skin looks like.

When they come to your unit, they should have a skin assessment so you know what it looked like when they got there. When they transfer from facility to facility, you need to know what it looks like. So often I have nursing homes say to me, “The hospital never told us the person had a pressure ulcer; but when they got here, they had a pressure ulcer.” Or the hospital says, “When we sent that patient to the nursing home, they didn’t have a pressure ulcer. But they came back now and they have one.” So we need to be able to see when that pressure ulcer really occurred.

Did they have the pressure ulcer when they left the hospital? Did they have it when they arrived at the nursing home? What happened in the nursing home? Obviously, if their condition hadn’t deteriorated, they wouldn’t have gone back to the hospital. But what happened? What was the chain of events, and how can we change that? In all reality, patients that have really long transportation times on hard surfaces to the hospital or are in the emergency room or been in surgery for over an hour have been found to be most likely to be the ones that have a pressure ulcer on admission to an Intensive Care Unit. So we need to think about what happened to the patient because they actually can start on the way to the hospital. That’s why it’s so critical to know what the skin looks like on admission anywhere in the hospital.

And this must be ongoing; it’s not one time. The frequency of the skin assessment can be as much as every shift. It needs to depend on the acuity of the unit that the person is in. Now, it’s not that the nurse has to run in and say, “I’m going to do a head to toe skin assessment from top to bottom.” It can be that it’s integrated into other care so that you’re doing parts of it throughout the day.

But when the patient is newly admitted, moved to a different level of care, transferred or discharged, it should be done head to toe before they leave and documented what you see there, what you see when you get them. You need to know what your policies and procedures are and make sure they’re being followed. But every time anyone on the staff puts oxygen on, adjusts the oxygen, the ears, areas of the tubing if there’s an oxygen mask where the elastic is, need to be checked. Look behind the ears; look around the ears.

Make sure they’re not laying on the oxygen tubing because it can cause a pressure wound under their shoulder. When you’re looking at things like bowel sounds — you’re listening to the patient — look at the skinfolds. Repositioning the patient in bed — always check the back of the patient’s head as well as their back itself. The CNAs and other staff can actually do this as well.

When you listen to lung sounds, look at their shoulders, their back and their sacral coccyx areas. Again, a lot of this is the CNAs that are turning the patients. Teach them how to do this. When you check the catheter, check the penis and make sure that there are no areas of pressure.

Make sure that where the catheter tubing goes around a leg strap is not too tight, that they’re not laying on their catheter tubing. I’ve seen pressure ulcers between the leg and the buttocks area from laying on the tubing. When you position pillows under the patient’s calves, check the heels and feet. Tall patients sliding down in bed can develop a pressure ulcer on the bottom of the foot from the footboard.

Teach your staff to use a small pocket mirror to look at the heels. I also teach my older patients especially or my bariatric patients to actually get an inexpensive hand mirror. Put it next to the toilet in the bathroom; and several times a week to look at their feet. Otherwise, they can’t see them; and our diabetic patients especially or our elderly, can have really large wounds on their feet without ever knowing it.

So use the opportunities for education as well. But a small handheld mirror that all the staff has can help them visualize the heels on a regular basis without having to elevate the bed or get down on their knees to look up. Teach your staff to also remove the socks to look at the feet every day. Often people come in with support hose or compression stockings, and they don’t know how to put them on correctly.

So they’ve either put them on and they’re twisted, or they haven’t taken them off because they didn’t know what to do when they’ve gone home. And they’ve caused areas of pressure or compressed the circulation to the feet. So teach staff that socks have to come off for visualization of the feet and heels every day. When checking IV sites, look at the arms and elbows.

The woman in this picture actually developed a pressure ulcer on her arm from sitting in the chair all the time and using her arm to push on the arm of the chair. Now, she was an older lady who didn’t move well. She was receiving chemotherapy. She was confused.

And no one was checking her arm, and that’s what happened. When the person is lifted, check the bony prominences on the butt, on the sides, the back of the foot. They’re all areas that frequently develop wounds or pressure ulcers, especially from people sitting. When you remove any equipment, check the adjacent skin.

This includes tens units, restraints, splints, oxygen tubing, and endotracheal tubes. People can develop very large pressure ulcers around cervical collars and braces. Make sure these are being checked daily. The SVDs that we put on people after surgery actually are very effective in preventing blood clots in the legs.

But people don’t move because they have tubing coming off them. So while we’re helping one problem, we’re actually making another problem worse. So always keep in mind the effect of any equipment from the patient perspective. Now, no matter how good your skin assessment is, if you don’t document it, no one is going to know you did it.

So it’s really important to make sure all results are documented by everyone doing it. And that they’re not only documented but they’re reported. It can be in rounds, it can be in a team meeting, it can be profession to profession. “We checked the skin today, and there were no wounds.” “We checked the skin today, and the dressing was still where it was supposed to be; it was dry. ” In our electronic medical records, we need to put if there were no problems as well as what the problems were.

One of the issues that frequently comes up is that the documentation can go on multiple screens. This can be very confusing to the staff doing the documenting or for someone trying to follow what’s been going on. Make sure all staff knows where skin is documented in the medical records. Now, there can be a checklist of screens with the five parameters where everything is found.

There can be diagrams of bodies that you can write it on as you’re doing wound rounds so that you know you can document it later. But it’s important for all staff to know where and how to document results. This can include something for your CNAs to actually put what they looked at and what they found for the nurse to use later in the actual record documentation. One of the things included in the toolkit is a pressure ulcer identification pad.

And we actually had these made into sticky notes that were small, and we gave them to the CNAs. And we said, “Any time you see something on a patient, mark down where it was — the date, the name, the room number, et cetera — and give this to your nurse.” The idea was to have an effective method of communication that everybody knew what it was. It wasn’t just casually saying, “I was in Mrs. Smith’s room today, and I noticed her butt was kind of red.” The problem being if the nurse is in the middle of something, she might say, “Oh, okay, I’ll go check it.” But she stays busy. You have a code; you have new admissions; you have whatever going on; and by the end of the day, you’ve forgotten to do it.

So this allows a way for the nurse to say, “Okay, I checked this; I documented about it.” It’s a very effective communication tool. The other thing that CNAs have told me when I’ve done education for them is that often the nurses don’t pay any attention to them or discount what they say. This is where the effective communication comes in; it’s really got to be a team approach. And everyone needs to know how to report issues to the other person without fear of sanction.

So keeping in mind that unit culture is an important piece and having a way of communicating is critical to providing good care. Another thing that has been tried and is effective — and you’ve got to know your policy and procedures to know how much of this you can or can’t do — is for every patient, have a sheet where you’re documenting the day they were checked and whether or not they had a pressure ulcer. If they have a pressure ulcer, they get an individual sheet in the notebook that then tells where it is; the dimensions of it; if it’s a pressure ulcer, what stage; how many if there are multiples,; all the stages and information about them; and then the treatment for any wound. Some facilities have actually gone so far as to once a week, they put a picture for each wound in that documentation sheet or on it using a Polaroid camera.

That way, anyone on the staff can see exactly what the treatment orders are for each wound. And it’s very easy then for the wound team to go page to page, and you can see if the wound is improving or deteriorating. Not all facilities allow photographs of the wound. That’s why you need to know your policy and procedure.

You also would need to know where the book was because each unit tends to put things in the middle. So anytime there is new staff coming in, they need to be told what the policies and procedures are, where this book would be, what they need to be doing because it can be very unit-specific. Make sure the results of the skin assessment are reported in the shift changes. It shouldn’t be ignored just because the skin is normal.

If the person has a wound and there’s a dressing on it, that dressing frequently is only changed every two to three days. So today is day number two, it doesn’t get hanged until tomorrow; that needs to be reported to the next shift. “The dressing was clean and dry; it is to be changed tomorrow. ” There needs to be a way for that next shift to also know if something happened and the dressing falls off or becomes saturated. What are the orders? And so that’s why having a place where they’re kept up-to-date becomes very important.

If problems are found, then this needs to be reported to the healthcare provider and other members of the team, including your CNAs as well as the next shift. If nothing is found, then that should also be reported. “The person’s skin was warm and dry, no reddened areas were found,” needs to be part of that standard report that people just get in the habit of and don’t even have to think about. If your unit can keep a log, then review the log on a regular basis to make sure the comprehensive skin assessment was done for each patient.

It’s a great way for the QI person to be sure that the best practices are being done. Make sure the assessment and treatment orders are current, that they aren’t outdated for each patient. Everyone on the unit should know the incidence and prevalence rates. They should know them for each unit; they should know why they matter; and they should know where they’re posted.

They should know what the difference is between prevalence and incident. And some of this information can be found in the toolkit. Make sure all staff is very clear on who is going to be in charge of that comprehensive skin assessment, what’s going to be reported, that the nurse’s aide knows to examine the skin and every time they clean it reposition the patient. And that the nurse knows that she needs to document it.

Everyone needs to understand how critical this is for good care and, frankly, for preventing lawsuits in the future. Everyone needs to know when and why it should be conducted, as well as how to conduct it and what their responsibilities are. New staff — either nurses, CNAs, anyone who is just learning — should not feel threatened when they want to ask questions or they feel unsure. If you tell a new nurse or a new CNA to go in and assess the skin, you don’t know how comfortable they are actually doing it.

So encouraging peer mentoring — let me help you. I’ve found when I go into facilities if I go in and do it first and someone watches me and then the next time I watch them is one of the most effective ways for them to learn without feeling threatened. This helps people feel very confident in their skills and prevents errors. Encourage people to ask questions without being made to feel stupid, especially your CNAs.

Often they’re afraid to ask because they’re afraid that someone is going to think it;s just that they’re not knowledgeable and they anybody ridiculed. Encourage them to feel very comfortable reporting these skin abnormalities, and that’s very much a unit culture measure that they need to work on. For care planning, the skin assessment along with the risk assessment, really determines the care plan. The person has no moisture issues, but they have a pressure ulcer.

So what are we going to do? Do we do a bed? How often do we turn them? Where do we turn them? How often do they get up? Do we need a dietary consult for them? They’re all part of the care planning questions that need to be asked and addressed. It’s not if we do one, we do the other; okay they’re done. We need to make sure that the staff is comfortable then r relating these to the actual care. In the toolkit is a whole diagram of how to do skin assessment and care planning.

This is just the head to toe skin assessment pulled from it. In other words, we need to do both. We need to document, and we need to report any of these abnormalities to the healthcare provider. The critical piece that’s often overlooked is that we need to educate the patient and the family on our findings.

If we find something, tell them. “When we were turning your mother today, we noticed her bottom was a little red.” When I go in and am actually looking at a pressure ulcer on the foot or the bottom, I actually ask my cognitively intact patients if they want to see it. And I’ll literally take a picture and show it to them. Now, I might discard that picture so I don’t take it out of the facility.

But I often show it to them and say, “Here’s what I found, and here’s what we’re doing about it, and here’s what you can do to help me.” It’s a very powerful tool, and it keeps patients and families from feeling like we’re hiding something from them. This is the whole assessment and care planning diagram that’s Tool 3A in your toolkit. So understand they both go together; it’s not very separate processes. This webinar talked about our attributes and goals of comprehensive skin assessment.

We talked about how to conduct the comprehensive head to toe skin assessment and treat it as a separate process. We also talked about integrating the skin assessment into our normal workflow and documenting and reporting results. We need to improve comprehensive skin assessment skills and care planning associated with it. And we need to work with all staff in all of these measures.

Thank you for being such great listeners. I know you’re going to have questions, and we certainly can refer any of those to your QI specialists. We also have a list of resources at the end, as well as the specific information in your toolkit. Thank you so much for listening today, and I hope you go out there and really conduct some good assessments and do a good job of training your staff.

Thank you. Okay, I’m done. Any questions? Thank you, Karen, that was great — a very great presentation. And if I did it again, it would never come out the same.

No, of course not; but it’s a great amount of content that is going to be really helpful to the hospitals. Are there questions that anybody wants to ask? We should probably let folks unmute themselves if they have a question or two that they want to ask. Remember too that we’ll be following up with you to generate a list of questions and answers to some of those common questions that we know people will ask. Does anyone on the line have a question that they want to ask? Well, I either did such a good job that you had no questions; or you all fell asleep.

No, no, no, no, not at all. It could go either way there. A lot of information. I think it will go really well with the video.

Oh, I think so. I think–

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Source: AHRQ Patient Safety