As a Director of Nursing, your assessment skills must be tiptop. How are the skills of the staff you are entrusting with the care of our older residents in long-term care? Have you given the staff the tools and time required to accomplish comprehensive and compassionate assessments?

Skin Assessment Fundamentals

An assessment consists of three elements: the interview, observation, and tests. These components contain the building blocks for diagnosis and then treatment. This blog discusses the assessment interview. We can rely on past knowledge based on clinical practice if certain pieces are missing and take a trial-and-error approach to treatment, but it is always best to have as much information specific to the resident from the outset as possible. Understanding where the resident is in their knowledge of their issue is key. Interviewing residents and significant others for information on presenting issues, personal details, medical history, social history, family history, and current health status is vital. This information and our observations are ongoing assessments because a resident's condition can, will, and does change daily in some cases.

Geriatric Skin Changes: What's Normal and What's Not?

As persons age, many changes take place that affect the skin and that we will address, so observation and clinical examination of the person's overall vascularity, neurological status, locomotor function, skin and nails, and footwear are critical. The element of laboratory or hospital tests includes those tests analyzing urine, blood, bone, heart, and nerve status. As residents are admitted to the long-term care facility, a review of past and current laboratory results can provide insight into treatment of skin issues. Please do not dismiss these reports as old or irrelevant. These elements give us a framework for the plethora of information a clinician takes in the second they look at the resident. Yes, the minute you see your patient an assessment starts. What is their posture, the expression on their face, their color, any odors, or any motor-spatial issue recognized?

Age-Related Skin Changes: Normal and Abnormal

Let's start with knowledge of what are considered "normal" aging changes. For older adults it may often be difficult to accept that activities that were once easy have now become gradually more difficult, and eventually impossible to perform, but this doesn't happen overnight. We notice a gradual loss of vision, hearing, some muscle strength, and skin elasticity, slightly slower reaction time, and hormonal changes as our systems age. Residents of skilled nursing facilities are coping with physical changes such as weight loss, thinning hair, changing sleep patterns, stooped posture, fatigue, etc. They are also coping with feelings about these changes, personal losses, and emotions about being a resident in a nursing facility. Not all difficulties in older adults are unavoidable, however.

Some physical, functional, psychological, and emotional difficulties are the result of various diseases to which older adults are especially prone. It is important to be able to tell the two apart because, unlike the signs of normal aging, disease symptoms often respond to treatment and may become worse or life-threatening if ignored! Our responsibility is to see the resident as a whole, observe for signs and symptoms of changes, decline, and/or illness, and address and respond with appropriate clinical care while documenting our observations and seeking assistance for specific areas of expertise. An overview of normal aging changes includes the following

• Loss of height and stooped posture: bone density loss, skeletal "shrinkage," less muscle flexibility, joint changes, falls, and fractures
• Weight change: late-onset diabetes mellitus and unstable blood glucose levels, anorexia, poor dentition, dysphagia, loss of taste (from disease or medications)
• Potential for dehydration: dry, fragile skin and bowel and bladder problems
• Sensory and perception loss: sight, hearing, taste, and touch
• Slower metabolism secondary to slowing of body processes: reduced energy and greater tendency to fatigue
• Change in sleep as a result of pain, stiffness, incontinence, and cognitive issues

Conducting the Interview

An assessment interview is different from a normal conversation. An interview is an opportunity for gathering important information, deciding on a course of treatment, and/or solving a problem. The primary purposes of the skin assessment interview are to identify the cause of the resident's issues and to take appropriate action. This can best be achieved when the resident (or significant other) and the clinician work in partnership. You will need to use a range of questioning skills.

Open questions, such as "What do you think is causing the problem?" elicits answers beyond one word and possibly information you had not expected. Closed questions, such as "How long have you had diabetes?" get a more limited response. These types of questions can be used to focus an interview, to provide quick verification of information, but if used too much these questions can limit residents' involvement. In addition, you will want to use more probing questions in conjunction with your open and closed questions to elicit more detail. Asking "What makes you think the wound is linked to your circulation problems?" may give you a better insight into the resident's understanding of the issue and help with treatment compliance.

Use paraphrasing, reflecting, and summarizing to clarify what you are hearing from the resident, to gain as much information as possible to make your nursing diagnosis and decide on a course of treatment. Listening skills to apply during the interview are also very important. Eye contact, facial expression, posture, and gestures convey more than you may realize. Leading questions, such as "You don't smoke, do you?" should be avoided. This type of question adds an element of judgment and may provide only the answer you want to hear. Never assume that these skills are inherent in your nurses. Assess their abilities, and provide them time and tools.

Conclusion

The skin assessment interview in long-term care residents is a foundational step in the assessment process and provides key information that guides patient care.

About the Author

Susan M. Cleveland, BSN, RN, WCC, CDP NADONA Board Secretary, has been Wound Care Certified through the National Association of Wound Care since 2004. Currently she consults in long-term care and alternate-care settings on wounds, skin care, and various other issues. She has been employed in the long-term care setting since 1969 and spent 25 years in a long-term care rehabilitation facility where the focus was wound healing therapies. NADONA /LTC has been the leading advocate and educational organization for Directors of Nursing, Assistant Directors of Nursing, and nurses in long-term care since 1986. With 40 state chapters, it continues to be the largest organization representing nurses working in both post-acute and long-term care settings. NADONA/LTC offers a wide array of services to its members, including educational materials; conferences; executive fellows program, webinars, and scholarships; Nurse Leader, Licensed Practical Nurse, and Assisted Living certification programs; a mentoring program; and a quarterly journal, The Director. Through its publications and programs, NADONA/LTC reaches approximately 20,000 nurses who are employed in long-term care. For more information regarding NADONA/LTC, please contact their offices at 800-222-0539 or visit their website at www.nadona.org.