How to do it... Skin assessment

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New admissions can start making – or costing – skilled nursing providers significant sums of money almost immediately. A key factor is how efficiently and thoroughly a new resident is assessed and diagnosed by the nursing staff. Should an existing or pre-emergent skin problem be missed, residents' – and providers' – bottom lines, could suffer unnecessarily. Proper education ahead of time should put most providers on firm footing.

1. Do it now. That is the unanimous top priority for professional caregivers. Conduct a skin assessment as soon as possible after the new resident arrives.
"If you are going to consider 'avoidable' vs. 'unavoidable,' the assessment timing will be imperative," says Connie Phillips-Jones, RN, MSN, referring to possible legal or regulatory actions.
"My concern is they (providers) have so much time after admission to do their MDS assessment, there may be some delay" in performing the initial skin assessment, the director of clinical support for wound-care device supplier Longport Inc. adds. "The more time that passes between the time they come through the door and having skin assessment done, the less credible your defense will be."

2. Prompt does not mean too fast." Don't rush, and don't assume what you are told by the referring provider or other caregiver," Phillips-Jones says. "It's really important to review what the referring provider has said and make sure you go the area of the body in question and verify with your own assessment. Don't just put the referring provider's assessment in the back of the chart.

3. If you feel you need clarification or more clout behind a diagnosis:
"Get the medical provider (doctor) to support your documentation, if appropriate. Have him or her present upon admission, if you can," says Jennifer Pettis, RN, RAC-CT, a policy analyst and consultant for the New York Association of Homes and Services for the Aging.

4. Nurses have to be able to both recognize a problem exists and make the right diagnosis.
"A common mistake is folks may be assessing dermatitis that is due to incontinence as a Stage I (pressure ulcer) area and treating it as a pressure ulcer when it fact, it's not," Pettis says. "Then, you're treating a different problem and it's not appropriate care."

5. One clinical care consultant likes to start from scratch, so to speak, with new admissions.
"One of the things is to prepare the new patient with a complete bed-bath or shower upon admission. First, it's for infection control. You're eliminating everything they're bringing in, and you're starting fresh to assess the body at that time," says Diane Kubala, RN, CDON, of Phoenix-based Residents First.

6. The biggest things Kubala sees omitted from initial assessments are proper checks of the head and feet. "Usually, when patients are in the hospital, they were on oxygen or lying on their backs for a long period of time. Turning and positioning are not a big protocol in the hospitals, " she notes. "So we see people with loss of hair on the back of their head, and if they've used an oxygen mask, we see a lot of open sores behind the ears."
Inactive individuals also must be examined for heel sores, she stresses.
Once they lose the callous on the heel, the bone becomes more evident for high-risk breakthrough," she says. "As soon as they feel mushy heels or non-calloused heels, they need to report it."

7. Assessors must also be-come "culturally competent" to provide proper skin care, Phillips-Jones says.
"People with darker skin are more difficult to assess for a color change. The Stage I pressure ulcer is characterized by the national advisory council for its redness. If the skin is darkly colored, you're not going to see discoloring," she notes.

8. Intense visual inspection of the skin is important – but it can't head off all problems. Hands-on probing and other, more objective tools complement the process, Phillips-Jones asserts.
"Use an objective tool like a high-frequency/high-resolution ultrasound to see skin changes under the epidermis and not visible to naked-eye assessment," she recommends.