As part of our pressure injury prevention program, we conduct a weekly head-to-toe skin inspection. Can this be done by nursing assistants?
A weekly head-to-toe skin inspection is recommended as part of a pressure injury prevention program in the guidance of F686 Skin Integrity/Pressure Ulcers. However, the guidance does not indicate who should perform the inspection.
Nonetheless, I would suggest you have it performed by a licensed nurse because a licensed nurse has more advanced skills at inspecting the skin.
The weekly head-to-toe skin inspection can serve as a double-check to ensure that no skin concerns are going unreported and untreated. In many facilities, the nurses coordinate the head-to-toe skin inspection with the nursing assistant during the shower or bath.
Any abnormality, such as rashes, skin tears, bruises, cuts, abrasions or dry skin, etc. — not just pressure injuries — should be reported.
Nursing assistants and licensed nurses should all be trained to perform a proper skin inspection. The skin inspection should include both visualization and palpation of the skin for color, moisture, temperature, integrity and turgor. Palpation is important, especially in darker skin tones, as skin damage may not have visual changes. Instead, the area may have consistency changes such as firmness or bogginess and/or temperature changes compared to the surrounding skin. A resident also may complain of pain, burning or itching at a site with a potential skin concern.
Nursing assistants should inspect the skin and report any findings daily. Encourage nursing assistants to report their findings even if the skin concern looks old or is resolving.
The goal of skin inspection is to find skin concerns in a timely manner, ensuring that appropriate interventions are put in place to promote healing.
Please send your wound treatment-related questions to “Ask the Expert” at [email protected].
From the July 01, 2018 Issue of McKnight's Long-Term Care News
