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Skin Monitoring: Comprehensive CNA Shower Review

Perform a visual assessment of a resident’s skin when giving the resident a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems to the DON for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number.

RESIDENT: _______________________________________________ DATE:_______________________

Visual Assessment

1. Bruising

2. Skin tears

3. Rashes

4. Swelling

5. Dryness

6. Soft heels

7. Lesions

8. Decubitus

9. Blisters

10. Scratches

11. Abnormal color

12. Abnormal skin

13. Abnormal skin temp (h-hot/c-cold)

14. Hardened skin (orange peel texture)

15. Other: _________________________

CNA Signature:_________________________________________________________ Date: ____________________

Does the resident need his/her toenails cut?

Yes No

Charge Nurse Signature: ________________________________________________ Date: ____________________

Charge Nurse Assessment:___________________________________________________________________________

_________________________________________________________________________________________________

Intervention: ______________________________________________________________________________________

_________________________________________________________________________________________________

Forwarded to DON:

Yes No

DON Signature: ________________________________________________________ Date: ____________________

Document available at www.primaris.org

MO-06-42-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare

&Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily relect CMS policy. Adapted from Ratlif Care Center.

Common mistakes

Completing the CNA Shower Sheets form accurately is essential for ensuring the health and safety of residents. However, many individuals make common mistakes that can lead to misunderstandings or inadequate care. One frequent error is failing to conduct a thorough visual assessment of the resident's skin. A comprehensive evaluation is crucial, as it allows for the identification of any abnormalities that may require immediate attention.

Another common mistake involves not reporting abnormal skin conditions promptly to the charge nurse. It is vital to communicate any findings immediately, as delays can result in further complications for the resident. Additionally, some CNAs may neglect to use the body chart provided to accurately describe and graph the location of abnormalities. This oversight can hinder the ability of healthcare professionals to assess the situation effectively.

Inconsistent terminology can also lead to confusion. For example, using vague descriptions such as "bad rash" instead of specifying the type of rash can result in miscommunication. Similarly, failing to document the exact date and time of the assessment can create gaps in the resident's medical history. Accurate documentation is essential for continuity of care.

Another error occurs when CNAs forget to sign the form. A signature is not merely a formality; it signifies accountability and professionalism. Furthermore, some individuals may overlook the section regarding toenail care. Not indicating whether the resident needs toenails cut can lead to neglect of this important aspect of personal hygiene.

In addition, CNAs sometimes fail to provide a detailed charge nurse assessment. This section is critical for outlining any interventions that may be necessary. If this information is lacking, it can impede the quality of care the resident receives. Lastly, not forwarding the form to the Director of Nursing (DON) when required can prevent essential follow-up actions from taking place.

Awareness of these common mistakes can help improve the accuracy and effectiveness of the CNA Shower Sheets form. By taking the time to review and complete the form diligently, CNAs can contribute significantly to the well-being of the residents they care for.

Dos and Don'ts

When filling out the CNA Shower Sheets form, it is essential to follow specific guidelines to ensure accuracy and clarity. Here are some dos and don'ts to keep in mind:

  • Do perform a thorough visual assessment of the resident's skin during the shower.
  • Do report any abnormalities to the charge nurse immediately.
  • Do use the body chart to accurately describe and graph any abnormalities.
  • Do ensure that all sections of the form are completed before submitting.
  • Don't use vague language when describing skin issues; be specific.
  • Don't forget to sign and date the form after completion.
  • Don't leave any questions unanswered, especially regarding toenail care.
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Similar forms

The CNA Shower Sheets form serves a specific purpose in monitoring residents' skin health during showers. Several other documents share similar functions, focusing on health assessments and care documentation. Here are four documents that are similar to the CNA Shower Sheets form:

  • Skin Assessment Form: This document is used to evaluate the overall condition of a resident's skin. Like the CNA Shower Sheets, it requires detailed observations and descriptions of any abnormalities, ensuring that caregivers can track changes over time.
  • Incident Report Form: When a resident experiences a fall or injury, this form documents the incident. Similar to the CNA Shower Sheets, it emphasizes the need for immediate reporting and thorough documentation of observed issues to ensure proper follow-up and care.
  • Hold Harmless Agreement: This agreement, commonly utilized in Florida, helps mitigate liability concerns during activities involving risks, ensuring that parties can engage in practices safely. For more information, refer to TopTemplates.info.
  • Care Plan Review Document: This form outlines the individualized care plans for residents. It parallels the CNA Shower Sheets by incorporating specific observations related to skin health, allowing caregivers to adjust care strategies based on documented assessments.
  • Daily Nursing Progress Notes: Nurses use this document to record daily observations and changes in a resident's condition. Like the CNA Shower Sheets, it highlights the importance of continuous monitoring and documentation of any health concerns to facilitate effective communication among the care team.