We have a high number of admissions each week. What assessments and interventions should we consider for skin integrity upon admission?
A head-to-toe skin inspection and a skin integrity risk assessment should be completed within the first 24 hours. It is imperative for the nurses who do your admissions to complete both. Based on the findings of the skin inspection and risk assessment, a temporary care plan should be developed and communicated to the nursing assistants.
At a minimum, the temporary care plan should address the following:
• Type of pressure-redistribution mattress
• Wheelchair cushion
• Heel lift
• Turning and repositioning schedule
• Incontinence management
• Dietary consult
• Therapy consult as needed
• Restorative nursing as appropriate
• Daily skin inspection by the nursing assistants during cares
• Weekly head-to-toe skin inspection by the licensed nurse
• Reporting of any skin concerns to the physician/practitioner and family/designee
• Risk assessment per facility policy
If the resident has a pressure injury or wounds upon admission, the temporary care plan should also address the following:
• Topical treatment as ordered
• Weekly comprehensive wound assessment
• Monitoring for signs and symptoms of infection
• Reporting of any concerns or decline to the physician/practitioner and family/designee
Obtaining as much information as possible prior to admission can ensure you have the proper equipment and supplies to care for the resident upon admission.
From the June 6, 2019 Issue of McKnight's Long-Term Care News
