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5.16 – Skin Assessment and Care (ICF)

Open Door is responsible for assessing and monitoring skin condition for each individual.  The purpose of skin care serves as:

  • Prevention of formation of skin conditions or wounds from developing
  • To improve or further prevent existing conditions or wounds

Overall skin observations will be completed during providing hygiene care daily by DSP staff.  Any issues noted must be reported to Incident Hotline and to nurse.  Upon any report of possible skin concern, the nurse will complete a physical observation and assessment of skin and document accordingly in medical records. The nurse is responsible for any follow-up needs related to further treatment.

The following procedures will be implemented for all individuals:

  • Quarterly skin assessments will be completed by assigned nurse.
  • Quarterly Braden Scale assessments will completed annually and at request of nursing or physician. (see attached)
  • The Braden Scale will be scored to identify risk and reviewed in individual plan:
    • Very High Risk: Total score ≤ 9.
    • High Risk: Total score 10-12.
    • Moderate Risk: Total score 13-14.
    • At Risk: Total score 15-18
    • Low risk above 18
  • The score will determine how often skin assessments will be completed in addition to quarterly assessment by nurse unless otherwise indicated in plan.
    • Very High Risk = Weekly assessment
    • High Risk = Monthly assessment
    • Moderate Risk, At Risk, Low Risk = Quarterly
  • When risk is identified, the team will enact measures to address the risk, including but not limited to:
    • Preventing pressure-turn schedules, repositioning schedules, heel/elbow and other protective padding
    • Maintaining good nutritional status
    • Keeping areas clean and dry
    • Assessing adaptive equipment needs
    • Obtaining order for treatment from Physician
    • Consult with wound nurse or other specialist
    • Skin protectants or other treatments as ordered by physician
  • For active pressure sores/wounds:
    • Followed up and assessed weekly by wound nurse. 
    • The wound nurse completes own progress notes including observations of wound’s location, stage, odor, length/width, depth, color, drainage, necrosis, debrided, granulation status and forwards to nursing department.  These notes are filed in wound chart with pictures. 
    • Wound nurse rounds will be completed by Medical Appointment Nurse.  Pictures of wounds will be taken by Medical Appointment Nurse during the rounds and filed appropriately in Individual Chart.
    • Dietician must be involved to monitor and ensure nutritional status

Last Revised: 8/25/21

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