Prevention, correct staging, precise measurable charting, immediate SBAR escalation for the findings that kill, and a hard line between what a UAP may observe and what only an RN may assess — those five behaviors are what make skin care nursing rather than housekeeping. Work all six benches.
Load a patient
Score the six subscales
Assess on admission, at every shift change or per facility policy, and with any change in condition.
What you see
Call it
At the bedside
Select every element that belongs in the note
Chart what you observed and measured, not what you concluded.
Findings
Your call
The call you are about to makeYou are Marcus Reed, RN, on 4 West. Mr. Alvarez, room 412, 62 years old, admitted two days ago for cellulitis after a lawn-mower laceration, on IV vancomycin, type 2 diabetes with an A1c of 9.4. At 1800 you marked the border of the erythema at the ankle. It is now 3 cm past that mark, the skin is dusky with two tense bullae, you feel crepitus over the lateral calf, and his pain is 9 out of 10 and out of proportion to what you see. T 38.9, HR 124, RR 26, BP 92/54 (down from 132/78), SpO2 94 percent on room air.
S — Situation
Who you are, who the patient is, and the one sentence that says why you are calling.
The task
Who does it?
Braden scoreSix subscales, total 6 to 23. Lower is higher risk.
Stage the woundDepth of tissue loss decides the number.
0
correct
0
attempted
13
wounds
Build the noteLength head-to-toe, width side-to-side, everything in centimeters.
Triage the findingSome skin findings buy you hours. These do not.
0
correct
0
attempted
12
patients
Make the callSituation, Background, Assessment, Recommendation.
Right task, right personUAP observe and report. RNs assess.