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Skin Assessment

Skin Assessment. Check skin when giving personal care If patient is complaining of discomfort or pain Check areas at risk of pressure damage (see body chart ) If area is red , check for blanching Document if skin is at risk such as very dry or over moist. Assess for problem skin

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Skin Assessment

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  1. Skin Assessment • Check skin when giving personal care • If patient is complaining of discomfort or pain • Check areas at risk of pressure damage (see body chart ) • If area is red , check for blanching • Document if skin is at risk such as very dry or over moist • Assess for problem skin • Assess any breaks/wounds to skin • What skin regime are they presently using ? • Can patient check and maintain their own skin health? • Have they got carers to help them with personal care

  2. Surface • Check what mattress and cushions they are using • Is it the correct surface level of risk ? • Check that mattresses and cushions are correctly installed and working –plugged in ,pumped up ,foamsintegrity (fist test) • What is the patient laying on –pads ,kylies (do they need to?) • Sheets- are they wrinkle free? • Baggy clothing • Do they need their surface upgrading or replacing?

  3. Incontinence • Have they been incontinent ? • Urine or faeces • Are they wearing pads –how often are they changed ? • Do they need a continence assessment? • What is their skin regime? • Do they need emollients ? • Skin barriers • What are they washing with? • Any problems with moisture –moisture lesions • Function - can they get to the toilet? • What is their toilet regime?

  4. Keep moving • Can they move • Are they motivated to move • Do they need prompting • Do they need assistance to move • Is there anything we can do to make they more independent • Do they need referring-OT /PHYSIO • Do they have/need a turning regime ? • Do they a positioning plan ? • Has the patient been educated to move every 1-2 hours stand / change position ,rest on the bed • Do they need passive exercises to prevent contractures

  5. Nutrition • MUST has it been done ,when was it, done is it current? • Is the patient at risk ? • What is the action plan /care plan • Has the plan been followed?if not why not ? • What are they eating and drinking? Does the patient know what a good diet is? • Do they need a food chart ? • Do they need a fluid chart ? • Can they fill their own chart in? Can a carer help? • Do they need a high calorie diet ? • Do they need a high protein diet (do they have any renal problems ) • Do they need referring ?

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