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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.

Document Information

Fact Name Description
Purpose of the Form The CNA Shower Sheets form is used to document a visual assessment of a resident's skin during showering, ensuring any abnormalities are reported promptly.
Assessment Items The form includes a checklist of skin conditions to monitor, such as bruising, rashes, and lesions, which must be recorded accurately.
Signature Requirements Both the CNA and the charge nurse must sign the form, confirming that the assessment has been completed and reviewed.
Legal Compliance This form is governed by state-specific regulations regarding resident care and documentation, such as the Missouri Revised Statutes Chapter 198 for long-term care facilities.

Cna Shower Sheets - Usage Guidelines

Completing the CNA Shower Sheets form is an important step in ensuring the well-being of residents during their shower. This form allows for a thorough assessment of the resident's skin and any potential abnormalities. Follow the steps outlined below to fill out the form accurately.

  1. Begin by entering the resident's name in the space provided next to RESIDENT:.
  2. Next, write the date of the assessment in the DATE: field.
  3. Conduct a visual assessment of the resident's skin during the shower.
  4. Identify any abnormalities based on the provided list. Mark each abnormality on the body chart by number.
  5. For each identified abnormality, provide a description in the designated area.
  6. Indicate whether the resident needs their toenails cut by selecting Yes or No.
  7. Sign the form in the CNA Signature: section and include the date.
  8. Have the charge nurse sign the form in the Charge Nurse Signature: area and write the date.
  9. In the Charge Nurse Assessment: section, provide any additional observations or comments regarding the resident's condition.
  10. Outline any interventions that were taken or recommended in the Intervention: section.
  11. Finally, indicate whether the information has been forwarded to the Director of Nursing (DON) by selecting Yes or No.
  12. Have the DON sign the form in the DON Signature: area and include the date.

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Dos and Don'ts

When filling out the CNA Shower Sheets form, it is crucial to follow specific guidelines to ensure accuracy and clarity. Here is a list of things you should and shouldn't do:

  • Do fill in the resident's name and date clearly at the top of the form.
  • Do conduct 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.
  • Don't skip any abnormalities; ensure all observed issues are documented.
  • Don't use vague language; be specific in your descriptions of skin conditions.
  • Don't forget to sign the form and include the date after completing the assessment.
  • Don't leave any sections blank; all required fields must be completed.

Common mistakes

  1. Incomplete Resident Information: Failing to fill out the resident's name and date can lead to confusion. Each form should clearly identify the resident to ensure accurate record-keeping and follow-up.

  2. Neglecting Skin Abnormalities: Not reporting visible skin issues such as bruises or rashes can result in serious health complications. It's essential to document and communicate any abnormalities during the shower assessment.

  3. Improper Use of the Body Chart: Mislabeling or omitting the location of skin abnormalities on the body chart can hinder effective treatment. Use the chart accurately to ensure that the charge nurse understands the specific areas of concern.

  4. Skipping Signatures: Failing to obtain the necessary signatures from the CNA and charge nurse can lead to accountability issues. Each signature verifies that the assessment and any interventions were properly conducted and reviewed.

  5. Ignoring Toenail Care: Not indicating whether the resident needs toenail trimming can overlook an important aspect of personal care. This information is crucial for maintaining the resident’s overall hygiene and comfort.

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