Skin assessment template PDF

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Summary

ATI TEMPLATE...

Description

ACTIVE LEARNING TEMPLATE:

Nursing Skill

LVN STUDENT NAME _____________________________________

assessment SKILL NAMESkin ____________________________________________________________________________

pg 163 fundaentals

REVIEW MODULE CHAPTER ___________

Description of Skill Assessment of pts entire skin on body, assess for abnormalities, injuries, echymosis, rashes, pressure ulces, wounds, scars. examination is performed by looking and touching skin throughout the body. special consideration to bony porminences.

Indications pt who is a new admit, has wounds/pressure ulcers, who is at risk for skin breakdown, pt who is bedridden, has limited ROM, pt who has fallen and has injuries, weekly skin assessments.

Outcomes/Evaluation nurse will asses and locate any injuries, skin breakdown, or abnormalities and prevent more from occuring. Nurse will document properly

Potential Complications Infection in wounds, prevent wounds from worsening. abnormalities can cause other issues within the body.

ACTIVE LEARNING TEMPLATES

CONSIDERATIONS

Nursing Interventions (pre, intra, post) make sure there is privacy, make pt feel comfortable, explain what you will be doing and throughout the process of assessment. Minimize the amount of skin exposed at one time. wear gloves. Nurse will evaluate both sides of body for symmetry. change pt to gown for easier assessment.

Client Education client education should include how to prevent skin breakdown, abonormalities, wounds and how to treat them. Good hygiene is necessary to prevent infection. Educate on medications administered, topical/Po for infection. Prevent falls that may reinjure or worsen wound. Hydration/nutrition is essential for healing.

Nursing Interventions administer medications as prescribed, ensure temperature of the room is confortable. assess skin color and temperature, drainage, necrosis debridment. skin turgor, monitor for cyanosis, assess hair, skin, nails, teeth, eyes, pulses, muscle tone, edema, lessions, and evaluate geriatric patients in a different scale for normal ranges due to atrophy.

THERAPEUTIC PROCEDURE

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