SKIN- Nursing Assessment Guideline

Whenever a resident has a new or worsening dermatological condition (rash, pruritus, redness, edema, etc.), the following evaluation should be completed before the decision is made both to observe and treat with nursing measures or to call the provider on call.

                       History:

1.        What are the specific changes noted on the skin?

2.        When did these signs and symptoms begin?

3.        Were any nursing measures tried and did they work? (topicals, antipruritic medication)

4.        Is there a history of this or other dermatological conditions?

5.        Is there a change in medications or topicals?

6.        Has the resident been ill in any other way in the past few days?

7.        Was the resident complaining of pain in this skin area before any skin change became evident?

8.        Are there others on unit with similar skin conditions?

9.        Has anyone recently been treated for confirmed or presumed scabies?

10.    Is there a history of a food or drug allergy?

11.    Is the resident on dialysis?

                      Physical:

12.    What are the vital signs?

13.     If diabetic, what is the Accucheck reading?

14.    Assess and describe skin condition. If a rash, describe pustules, blisters, scratch marks, etc.

15.    Note pruritus and whether it is worse during day or night.

16.    Note drainage and describe in terms of color, amount, and odor.

                       Response:

A.        Treat symptoms with PRN medications.

B.         If accompanied by severe symptoms, not responding to PRNs or accompanied by decline in overall status or if there is facial edema present call on-call provider.

NOTIFICATION CATEGORIES:

Emergency: Sudden onset of significant facial edema.

Routine: Worsening condition or no improvement within 48-hour period or to obtain initial PRN orders.

Revised 2/04