Skin

A comprehensive skin assessment establishes a baseline and detects change. It is not limited to finding an open wound. Skin colour, integrity, temperature, moisture, turgor, lesions, pressure areas, and the client's symptoms must be considered together because a single observation can be misleading. Pressure, shear, moisture, impaired circulation, inflammation, infection, and medication effects can all alter the skin. Pressure can damage skin or underlying tissue, usually over a bony prominence or where a medical device contacts the body. Tissue changes may develop before an ulcer is visible. Moisture can also injure the skin and can coexist with pressure damage. These mechanisms explain why pain, firmness, warmth, coolness, or a persistent colour change can be clinically significant even when the skin is intact. An RPN completes comprehensive health assessments and responds to the findings within legislated scope, individual competence, the care context, and employer policy. An order or additional authorization may be required for a treatment, diagnostic test, or intervention outside that authority. When findings exceed the RPN's competence or authority, protect the area, document the findings, and promptly notify the...