This week we are continuing our discussion of the patient in a correctional facility with a skin complaint. In our discussion, we will be using the SOAPE format for evaluation and documentation. When examining a patient with a skin complaint, it is very important to get a thorough history, including documentation of any allergies to foods, materials, and plants, and if this has ever happened to the patient before. Also ask if there has been any change in personal hygiene products, laundry soaps, etc.
The Objective part of the evaluation of a patient with a skin complaint is the physical examination. Using the appropriate, descriptive words for the skin lesion(s) you see, in the objective part of the exam you should complete an inspection and palpation of the area/lesion(s). Vital signs should always be measured, and the patients’ heart, lungs, and abdomen should be evaluated through auscultation and palpation as applicable. In addition to the affected area, other parts of the body should be inspected to ensure that the rash/lesions have not spread, if it is suspected to be a condition that typically does so (drug reaction, general food allergy reaction, Rocky Mountain Spotted Fever).
In the SOAP/SOAPE format of documentation, the Assessment is the area where, based upon licensure and scope of practice, nurses should document applicable nursing diagnoses. These are not medical diagnoses – only providers can diagnose the medical/mental health problems of the patient. I understand that states vary with regard to the legal ability of licensed vocational /practical nurses to make a nursing diagnosis. It is extremely important that you know the scope of your practice, and function within those boundaries. I also understand from my academic nursing colleagues that some schools of nursing are now not teaching the development and use of nursing diagnosis to guide the nursing plan for the patient, but I have included a couple of nursing diagnosis that may be appropriate for the patient with a skin problem: Alteration in skin integrity related to boil/fungus/ carbuncle; Alteration in Comfort-itching (pruritis)-related to exposure to poison ivy; Alteration in Skin Integrity related to exposure to an unknown trigger.
The Plan is what nursing staff is going to do for the patient, and is typically based upon your Nursing Guideline (Protocol, Template) for skin. If you do not have nursing guidelines/protocols to follow, then your plan most likely will be to contact a provider for consultation/orders. It is important to document who you spoke with and what you told the provider, and include any provider orders received in your documentation. Finally, patient education regarding the condition, including self-care, medication, reasons to notify healthcare staff and any follow-up necessary should occur. All actions for this patient should be documented in the health record.
Do you use Nursing Diagnoses in your correctional nursing practice?
Do you have an unusual skin presentation that you have encountered in your correctional nursing practice? Please share your experiences so we all can learn!
Also check out our Documentation for the Correctional Nurse class.