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DATE OF SERVICE AGING AND LONGTERM SUPPORT ADMINISTRATION (ALTSA)Nursing Services Basic Skin Assessment (Integumentary System Skin, Hair, Nail) CLIENT NAMEDATE OF BIRTHCM / RN NAME REFERRING RN NAMECLIENT.

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How to fill out the Nursing Services Basic Skin Assessment (Integumentary System) online

Filling out the Nursing Services Basic Skin Assessment is an essential step in evaluating a client's skin health. This guide will help you navigate the process online, ensuring all necessary information is accurately entered to promote effective care and assessment.

Follow the steps to complete your assessment online.

  1. Select the ‘Get Form’ button to access the Nursing Services Basic Skin Assessment in your browser.
  2. Enter the client's name and date of birth in the designated fields to identify the individual you are assessing.
  3. Provide the names of the case manager or registered nurse and the referring registered nurse.
  4. Fill in the client Aces ID and client provider one ID in the respective sections to ensure proper record-keeping.
  5. In the 'Request related to' section, check all relevant options to indicate the focus of the assessment, including skin observation and any other referral types.
  6. Move to the Injuries Assessment Section and number all integumentary issues, starting from #1, and detail each issue type, such as pressure injuries or skin rashes.
  7. In the 'Basic Skin Assessment – Additional Detail' section, check off or note relevant history regarding the skin condition, including duration, frequency, and family history.
  8. Review and provide comments on temperature, turgor, moisture, skin integrity, and the condition of nails and hair.
  9. Add notes for any foul odor, moles observed, and any non-injury recommendations for follow-up care.
  10. Once all information is filled out, ensure accuracy and completeness before saving your document. You may choose to download, print, or share the completed assessment.

Complete your Nursing Services Basic Skin Assessment online today for effective client care.

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The general appearance of the skin is assessed by observing color, temperature, moisture or dryness, skin texture (rough or smooth), lesions, vascularity, mobility, and the condition of the hair and nails. 19. Palpation Skin turgor, possible edema, and elasticity are assessed by palpation.

A skin assessment needs to be repeated whenever a person is identified as at high risk as a result of a pressure ulcer risk assessment, to take account of any changes to the skin and to ensure patient and service user safety.

A routine integumentary assessment by a registered nurse in an inpatient care setting typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill.

A skin assessment should include the presenting concern/compliant with the skin, history of the presenting concern/compliant, past medical history, family history, social history, medicines (including topical treatment) and allergies and impact on quality of life.

Information gathered from the skin inspection and aspects of management should be clearly documented in the patient's notes and care plan. Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.

Skin. Skin appendages. Hairs. Nails. Sweat glands. Sebaceous glands. Subcutaneous tissue and deep fascia. Mucocutaneous junctions. Breasts.

How do I do the assessment? Explain to the patient and family that you will be looking at his or her entire skin and explain the purpose to identify potential problems. Perform the assessment in private. Minimize exposure of body parts during the skin assessment.

A skin assessment should include an actual observation of the entire body surface, including all wounds*, inspection of hair, nails, skin folds and web spaces on hands and feet, systematically from head to toe.

Information gathered from the skin inspection and aspects of management should be clearly documented in the patient's notes and care plan. Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.

Temperature. Color. Moisture level. Turgor. Skin integrity (skin intact?)

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