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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.

Documents used along the form

In the realm of healthcare documentation, particularly in facilities like nursing homes, various forms work together to ensure comprehensive care and accurate reporting. The CNA Shower Sheets form is crucial for monitoring residents' skin health during showers. However, it often accompanies several other documents that enhance the overall care process. Below are some commonly used forms that complement the CNA Shower Sheets.

  • Skin Assessment Form: This document provides a detailed evaluation of a resident's skin condition. It typically includes sections for documenting the history of skin issues, existing wounds, and any treatments applied. It serves as a baseline for ongoing monitoring.
  • Care Plan: A care plan outlines the specific needs and goals for each resident. It includes interventions based on assessments, such as those noted on the CNA Shower Sheets, ensuring that all staff members are aware of the tailored care required for each individual.
  • Incident Report: When any unusual event occurs, such as a fall or skin injury during a shower, an incident report is completed. This document details what happened, the response, and any follow-up actions, helping to maintain safety and improve care protocols.
  • Power of Attorney Form: This form allows you to appoint an agent to make healthcare decisions on your behalf when you are unable to do so. It is crucial for ensuring your medical decisions align with your wishes. For more information, visit https://legalpdfdocs.com.
  • Daily Nursing Notes: These notes capture the daily observations and care provided to each resident. They often include updates on skin conditions, responses to treatments, and any changes in the resident’s overall health, creating a comprehensive record of care.
  • Medication Administration Record (MAR): This form tracks all medications administered to residents. If a resident requires treatment for skin issues, the MAR ensures that any relevant medications are documented, providing a complete picture of their care.
  • Resident Assessment Protocol (RAP): This document is part of the MDS (Minimum Data Set) and helps identify potential issues that may need attention, including skin integrity. It guides care planning and ensures that all aspects of a resident's health are considered.

Together, these forms create a robust framework for monitoring and documenting residents' health, particularly regarding skin integrity. By utilizing these documents, healthcare providers can ensure that they deliver thorough and attentive care, ultimately enhancing the quality of life for residents.

Similar forms

  • Skin Assessment Form: Similar to the CNA Shower Sheets, this document focuses on evaluating the condition of a resident's skin. It requires the caregiver to note any abnormalities, providing a systematic approach to skin care. Both forms emphasize the importance of timely reporting to nursing staff.
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  • Incident Report: This document captures details of any unusual occurrences affecting a resident's health or safety. Like the CNA Shower Sheets, it requires immediate attention and documentation of specific findings, ensuring that all incidents are recorded and addressed promptly.
  • Daily Care Log: This log tracks the daily activities and health observations of residents. It shares similarities with the CNA Shower Sheets in that both require caregivers to document specific details about the residents’ well-being, fostering accountability in care practices.
  • Fall Risk Assessment: This document evaluates the likelihood of a resident falling. It parallels the CNA Shower Sheets by requiring caregivers to assess and report on specific risk factors, thereby promoting proactive measures to enhance resident safety.
  • Medication Administration Record (MAR): The MAR tracks medications given to residents, similar to how the CNA Shower Sheets document skin conditions. Both forms require accurate recording and timely communication with nursing staff to ensure proper care and medication management.

Misconceptions

Misconceptions about the CNA Shower Sheets form can lead to confusion and improper use. Here are four common misunderstandings:

  • Misconception 1: The form is only for documenting severe skin issues.
  • Many believe that the CNA Shower Sheets form is only necessary for serious conditions like deep wounds or infections. In reality, it is essential for recording all skin abnormalities, including minor issues like dryness or minor bruising. Every detail matters, as early detection can prevent more significant problems.

  • Misconception 2: Only the charge nurse can make entries on the form.
  • Some think that only the charge nurse has the authority to fill out the form. However, CNAs play a critical role in the initial assessment. They are responsible for documenting their observations and reporting them to the charge nurse, who then adds their assessment and any necessary interventions.

  • Misconception 3: The form is optional and can be skipped if there are no visible issues.
  • This is a dangerous belief. The CNA Shower Sheets form is a required part of the care process. Even if a resident appears to have healthy skin, a visual assessment must still be conducted. Regular documentation helps maintain a comprehensive record of the resident's skin health over time.

  • Misconception 4: The body chart is only for visual reference and does not need to be filled out.
  • Some individuals may think the body chart is merely illustrative. In fact, it is a crucial component of the form. Accurately marking the location and type of skin abnormalities helps ensure that all team members are aware of specific issues and can monitor changes effectively.

Understanding Cna Shower Sheets

  1. What is the purpose of the CNA Shower Sheets form?

    The CNA Shower Sheets form is designed to facilitate a thorough visual assessment of a resident's skin during their shower. This form serves as a tool for Certified Nursing Assistants (CNAs) to document any abnormalities they observe, such as bruising, rashes, or lesions. By recording these details, the form helps ensure that any potential issues are promptly reported to the charge nurse and addressed accordingly.

  2. How should a CNA use the body chart included in the form?

    The body chart is an essential component of the CNA Shower Sheets form. CNAs should use it to mark the exact locations of any abnormalities they identify on the resident's skin. Each abnormality should be numbered and described clearly. This visual representation aids in communication with the charge nurse and helps track changes over time.

  3. What types of skin abnormalities should be reported?

    CNAs should be vigilant in observing various types of skin abnormalities during the shower. The form lists several conditions that require attention, including bruising, skin tears, rashes, swelling, and dryness, among others. Any abnormal color, temperature, or texture of the skin should also be documented. Reporting these issues promptly can prevent further complications and ensure the resident receives appropriate care.

  4. What steps should a CNA take if they observe an abnormality?

    If a CNA observes any abnormalities during the skin assessment, they must report these findings to the charge nurse immediately. This is crucial for ensuring the resident's health and safety. After the charge nurse reviews the situation, any necessary interventions should be documented on the form. Additionally, the information may be forwarded to the Director of Nursing (DON) for further evaluation.

  5. Is there a section for documenting toenail care?

    Yes, the CNA Shower Sheets form includes a specific question regarding whether the resident needs their toenails cut. This section allows CNAs to ensure that all aspects of the resident's personal care are addressed. If the answer is yes, it can prompt further action to ensure the resident's comfort and hygiene.

  6. Who is responsible for signing the form?

    The form requires several signatures to ensure accountability. The CNA must sign and date the form after completing the assessment. The charge nurse also needs to sign and date it after reviewing the findings. If the situation is escalated to the DON, their signature is required as well. This multi-signature process helps maintain a clear chain of communication and responsibility in resident care.