What should be on our temporary care plan for skin integrity?
First, ensure your temporary plan of care is completed within 48 hours of admission.
The skin integrity care plan interventions should be individualized and based on the results of the skin inspection and skin integrity risk assessment. However, there are some interventions that always should be considered on the temporary skin integrity plan of care:
• Pressure-redistribution mattress
• Pressure-redistribution wheelchair cushion
• Turning and repositioning schedule and devices
• For immobile residents, a means of elevating the heels of the bed
• Incontinence management, with skin kept clean and dry
• Referrals as appropriate to Dietary and Therapy
• Daily monitoring of the skin condition by caregivers
• Head-to-toe weekly skin check performed by licensed nurses
• Skin integrity risk assessment per policy
• Staff reporting of all skin concerns to the nurse
• Notification of the physician/NP and family/designee of any skin concerns that are found
If a wound is present, also address (at a minimum):
— Topical treatment as ordered
— Weekly wound assessment by licensed nurses
— Monitoring of the wound for signs and symptoms of infection or decline
— Notification of the physician/NP and family/designee of any decline, changes in treatment, or concerns.
Once the temporary plan of care is developed, ensure the information is properly communicated and placed on the nursing assistants’ care sheets.
Please send your wound treatment-related questions to “Ask the Expert” at [email protected].
From the January 01, 2018 Issue of McKnight's Long-Term Care News
