Download 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
• 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
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 ,foams
integrity (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?
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?
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
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 ?