Wound Care, part 1: Introduction to Wound Care, Skin Assessment on Admission


In this first video, Cathy previews the content of this video series and talks about best practices when doing head-to-toe skin assessments for newly admitted patients.

Topics covered in this video series include the importance of a thorough skin assessment when a patient is admitted, how to stage and care for pressure injuries (previously pressure ulcers), how to care for common wounds (ex: skin tears, diabetic foot ulcers, moisture associated skin damage), and wound vacs (i.e. negative pressure wound therapy).

In this video series, Cathy Parkes BSN, RN, CWCN, PHN will help nurses and nursing students feel comfortable and confident in caring for their patient's wounds.

  • 0:00 What to Expect
  • 1:00 Skin Assessments
  • 1:18 Hospital Acquired Pressure Injury
  • 1:41 Consequences
  • 2:34 Best Practices
  • 2:48 Pressure Injuries
  • 3:31 Moisture Associated Skin Damage
  • 4:04 Diabetic Patients
  • 3:39 Wound Identification Procedure
  • 6:38 What’s Next?

Full Transcript: Wound Care, part 1: Introduction to Wound Care, Skin Assessment on Admission

Hi, I'm Cathy, and I am a certified wound care nurse. In this video series, I want to help nurses as well as nursing students to feel comfortable and confident in providing wound care for our patients. So in this video series, I will talk about how to do a thorough skin assessment, how to identify wounds, how to care for those wounds, and how to chart effectively on those wounds. I will also cover how to stage pressure injuries. And I will also talk about care of very common type wounds such as skin tears or moisture-associated skin damage related to incontinence. And then finally, I will be talking about wound VACs, what they're used for, how they work, how to troubleshoot issues with wound VACs, and how to change a dressing on a wound VAC. So those are some of the topics I want to cover in this playlist.

So I'm going to start off in this video by talking about how to do a thorough skin assessment when your patient is admitted. That skin assessment is probably going to be the most important skin assessment you'll do over the course of the patient's hospitalization. That is because if the patient comes in with a pressure injury that we don't identify and don't chart on within the first 24 hours of their admission, it becomes what we call a hospital-acquired pressure injury. And what does that mean? That means we officially caused that pressure injury. Doesn't matter if we're fairly confident that the patient came in with it. If we didn't document it within 24 hours, then we own it. We caused it, and we will not get reimbursed for the care of that injury, and we may get a visit from the state department to figure out why we had this outage. And we basically get dinged as a hospital. So finding and documenting pressure injuries as well as all other kinds of wounds is going to be super important to do within the first 24 hours. So if you are the admitting nurse, you're going to want to do a very thorough skin assessment. And you're going to want to do this for all your patients. It doesn't matter if your patient is 90 years old or 20 years old. You're going to want to do that thorough head-to-toe skin assessment. And it's always better if you can get a second nurse or other staff member to come in there with you to do this assessment because two sets of eyes is always better than one because things can get easily missed.

So what are you looking for when you do the skin assessment? Well, you're going to be looking for pressure injuries. This used to be called pressure ulcers, but the latest terminology is a pressure injury. Pressure injuries will occur over a bony prominence due to pressure. So if you think about all the bony parts of your body, this includes the back of your head, your scapula, your coccyx bone, or your sacrum, your heels, anywhere where there's a bony prominence, you're definitely going to want to take a look at that to see if there is a wound present. In addition, there are other types of wounds that you may see on your patient. If your patient is incontinent, then they may also have moisture-associated skin damage. So when you're doing your head-to-toe assessment, you definitely want to look within the buttocks, spread those cheeks and see what's going on there, because if the patient is incontinent, you will likely see redness or erythema and possibly a rash if they have a fungal infection. So you're going to want to identify and chart on that as well. For patients who have diabetes, diabetic foot ulcers are very common as well as other wounds. So some of these wounds can be found on the bottom of the feet. So when you're doing your assessment, you definitely want to take off your patient's socks and inspect their entire feet as well.

So do not skimp on this assessment. It's really important. Again, two sets of eyes is better than one. And you just want to go head to toe and check the front and the back and all the folds for the presence of wounds. When you find a wound, you want to take a picture of that wound, and you want to see if you can identify it. Sometimes, wounds are hard to determine whether they're a pressure injury or the result of diabetes or the result of moisture. If you can pull in your mentor nurse or your charge nurse to help identify what that wound is, that's great. They may be able to help you. If no one else is available or they're not sure what the wound is, then you just need to take your best guess on what it is. Again, pressure injuries will be over bony prominences. If it's not over a bony prominence, if a wound you find is not over a bony prominence, likely it is not a pressure injury. It's probably related to either some kind of trauma or diabetes or moisture.

So just take your best guess at what that wound is and document it in the patient's electronic medical record to the best of your ability, and then put in a wound consult if you're not sure about how to identify that wound or how to care for that wound. And we will come out and do an assessment on that patient. But as long as you took a picture and charted that wound in some way in the patient's chart, then we are covered from a hospital perspective. It will be clear that the patient came in with that wound, right? It was present on admission, and it won't be a hospital-acquired wound. So it's very easy for us after the wound care team comes and does an assessment to reclassify that wound. If maybe you thought it was a pressure injury, but it's not, or vice versa, we can easily fix that charting. But what we can't fix is if you didn't document anything on that wound for the first 24 hours. So that's why the first 24 hours, that first skin assessment, is so, so important. So hopefully, that's been helpful, and we will pick it up with more good wound care information in my next videos. Thanks for watching.

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