Skin Assessment

 Skin Assessment should be performed during admission and discharge to/ from the hospital, every shift, if Pt. conditions change, and at the emergency department. 

Complete assessment of the skin head to toe, paying attention to bony prominence because there can be the site for a pressure injury, aka bed sore. those are the most frequently bony prominences: 

*Sacrum/coccyx

*Buttocks

*Ischium

*Heels

Braden scale: Braden scale is a standardized and validated tool to determine pressure injury risk, It contains 6 items, sensory perception, moisture, activity, mobility, nutrition, and friction and shear. These helps in the decision-making and plan of care.

Assessing pressure related changes like temperature, cooler, warmer, blanch response, and pain or discomfort. Signs of pressure injury may include blanchable erythema, and or changes in tissue temperature or consistency.

"Blanchable" refers to an area of skin redness that turns white when pressure is applied, meaning the color disapears with pressure, while "non-blanchable" means the redness persists even when pressure is applied, indicating potentialtissue damage and often a sign of developing pressure ulcer. in dark skinn colors apply a wet wipe and use a tangential lighting, use a penlight to detect suspected erythema or color changes. 

Complete skin assessment include 

Skin Tones:  

*Pallor (paleness)

*Erythema (redness)

*Ecchymosis (bruising)

*Jaundice (yellow)

*Cyanosis (blue)

*Mottling ( spotty white)

Turgor:

When skin on the back of the hand is pinched, it should immediately return to normal. A variation of this may be indicative of dehydration or aging.

Temperature

Moisture

Skin Integrity:

* Intact

*Breakdown: open areas (skin tears, pressure injuries)

* Rash (fungal, bacterial)

*Moles, Freckles, variation in skin color or texture

Braden subscale: Sensory Perception

1) Completely Limited : unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body. Ex : comatose, sedated and intubated patient

2) Very Limited : responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Ex: Spinal cord injury below the waist, stroke with hemiparesis.

3) Slighly Limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits the ability to feel pain or discomfort in 1 or 2  extremities. Ex: Patient has diabetes and has neuropathy (can't feel pain in their feet)

4) No Impairment: responds to verbal commands. has no sensory deficit to feel or voice pain or discomfort.

Braden Scale Mobility: 

1) Completely Immobile: Does not make even slight changes in body or extremity position with assistance

2) Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3) Slightly Limited: Makes frequent though slight changes in body or extremity position independently.

4)No limitations: makes major and frequent changes in position without assistance.

Avoid : Egg mattresses, turning pacient onto a body surface that is still red from a previous episode of pressure loading.

Braden Scale Activity: bedfast, chairfast, walks occasionaly, no impairment. Avoid: long periods sitting, donut-type devices.

Braiden Scale Moisture: completely moist, very moist, slightly moist, rarely moist. Avoid hot water, plastic underpads, multiple layers of linens under patient, briefs in bed.

Recommended Interventions: turn and reposition every 2 to 3 hours, if unable to tolerate full turns, frequent micro turns every hour until stable. Heels if reclined, elevate off of footrest. Sacrum/lowe buttocks:consider application of multilayer foam dressing with silicone adhesive. Support surface: consider reactive overlay (specialty bed) or "sand bed" 

Braden scale Nutrition:

1)Very Poor: never eats a complete meal . Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly.. Does not take a liquid dietary supplement OR is NPO and or maintained on clear liquids or IVs for more than 5 days.

2) Probably Inadequate rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

3) Adequate eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutricional needs.

4)Excellent eats most of every meal never refuses a meal Usually eats a total of 4 more servings of meal and dairy products. Occasionaly eats between meals. Does not require supplementation.

Recommended Interventions: consult dietician if: NPO for more than 48 hrs, presence of stage 2 or greater pressure injury.

Braden Risk Category: Friction and Shear

Friction: occurs when the skin moves against another surface. Ex pulling a patient up in bed, pulling linens/tubes out from under patient, using elbows to push self up in bed.

Shearing: the pulling of two adjacent tissues in opposite directions,often resulting in tissue destruction Ex: High risk of shearing when HOB>30 degrees. Tissue and superficial fascia remain fixed against the bed linens while the deep fascia and skeleton slide down toward the foot of the bed causing deeper tissue injury.

Probem, potential problem, no apparent problem Avoid greater than 30 degrees head of the bed elevation.

Final notes: this entire presentation is from the mandatory courses provided by Ascension Seton, they are all standard tools to follow. The computer Cerner charting, program will give the score imediately when data is entered during charting. The only purpose of this presentation is educational purpose only.

 

How is a typical day of a nurse/ Brazilian nurse/ International nurse working at the IMC Intermediate care and Trauma MedSurg in the Hospitals in the USA

0615 Arrive at the Hospital. Go straight to the break room and put the lunchbag in the fridge, backpack in the locker, get flash light pen, pen, eraser pen, and stethoscope littmann out in the pocket or in the fannybag.

0621 Find the assignment with 4 to 5 patients assigned, go to the computer, quickly read the main reason for Pt. being in the hospital, procedures done, medication times, and antibiotics next dose, next pain medication dose, allergies, past medical history,

0639 Clock in, get report from the night nurse, ask to spell out the abbreviations, ask again if he or she speaks too fast, write down really quickly everything. X4 X5 Shift change meet and greet Pt. update the board with the date, nurse, PCT, patient care technician, charge nurse names, phone numbers (work phones) plan of care, pain control, goals of the day, etc

0720 to 0930 Pass medications of the 7, 8, and 9 hour medication, Synthroid first is given 2 hours before breakfast. Insulin short-acting following the sliding scale, first need to know from PCT how much was the last glucose results, Insulin Glargine Lantus is long-acting and it is usually given by prescription certain units.

Beta-blockers (Metoprolol, Carvidelol) Always check blood pressure and apical pulse before administering, if lower than 50 hold, some recommend to hold if pulse is lower than 60 and Systolic pressure lower than 100, Digoxin hold if Pulse is lower than 60. Hold heparine and betablockers if there is surgery or call the anesthesiologist to ask first. Some medications are held before hemodilalysis, usually hypertension medication. 

Narcotics Oxycodone step one and step 2, Dilaudid, morphine, Tramadol after pulling from the BD Pyxis (an automated medication dispensing system) YOU HAVE 30 MINUTES TO ADMINISTER the narcotics, if waste get a nurse witness to witness, if Pt. refuses pain medication return medication back to Pyxis BEFORE THE 30 MINUTES. Pain scale must be moderate to severe and POSS score must be completed  1 for awake and alert, 2 for slightly drowsy. 

Antibiotics double check if it's the initial loading dose which is usually given in 6 minutes, maintenance dose is given over 2 or more hours. For Vancomicin runs for 4 hours, when trough level is due, collect blood for lab from a fresh vein, 30 minutes before the next dose. Laboratory says it's normal 10 to 20mcg/mL that number can vary depending on each hospital 

Heparine or Lovenox is given SC usually on the lower abdomen.

Tip: wake up Pt, do a quick assessment head to toe, ask about pain, if constipation, numbness and tingling check arms and leg strength, pulses, eyes, level of consciousness pulses, heart, lungs, sensibility on operated leg toes, arms fingers, color temperature. Ask pt. his/her name and date of birth, scan medication, give medication unwrapped in the medicine cup, explain each and what it is, its side effects, open the chart begin charting the assessment, Cerner or Meditech select only a few items of charting, just to set the time and register important information, charting completely after passing all medication is better so they dont't  get too late.Check orders constalty, refresh your screen every 15 minutes. Get help from your PCT with perineal care comfort care, check the skin while wiping with warm sponges no rinse sponges dry with towel,  turning Pt with two-person assistance, mornings go by very quickly.

1110 finish charting on Cerner or Meditech

1200 Pass noon medication rounding every room again, collect blood for lab studies, check lab results, eletrolytes results, administer Potassium if level is low, following the sliding scale the Potassium PO dose must be given with meals. 

1230 bathroom break drink water.

1100 or 1300 meeting with the interdisciplinary team.

8000 to 1230 answer calls and texts from work phone, if there is a surgery get informed consent signed by the Pt for surgery, explain risks, and consent for blood transfusions if needed and risks sign as witness, if Pt, needs further instructions doctoe can explain procedure again. All procedures are written without abbreviations, put it in the binder, delegate CHG bath.

13:30 take your lunch break, yes, finally another bathroom break warm up in the microwave, relax enjoy your lunch.

1400 pass medication, finish charting, discharge or admission.

1500, 1600, 1700 1800 rounding educating teaching Pt & passing medication fluids. collecting blood if necessary.

1800 Ins and outs. fluids, charting of food and beverage, urine output, and last bowel movement are usually done by the  PCT, nurses can do it too, beverage and urine output empty measure cup, , chest tube drainage, mark with sharpie pen last measurement on the device, JP drainage, on drains section.

1800 pass medication if any

1900 give Pt. report to the night nurse. see here an example of a bedside report.

!930 to 1945 clock out, go home, and get some sleep. You made it woohoo!

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