Skin Assessment - Aged Care Royal Commission

MRA.0003.0001.1195

Skin Assessment

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Facility Name· Greenw~_Room No: UNADMITIED UR No /ACS ID: -DOB __....dmission NOT ADMITIED YET

COLDAGE

Report created on: 26/01/2019 6:40 AM by Tania Nanda [Registered Nurse Division

Pressure Ulcer Risk

NORTON SCORE

General physical condition Mental state Activity Mobility Incontinence Norton score

Poor Confused Chair Bound Immobile Doubly 8

PRESSURE ULCER PREVENTION

Pressure ulcer prevention strategies for this person

Pressure relieving devices to be used Other

Sensor Mat usage details - past and current

Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 ovemight. Ensure skin does not remain in contact with moisture for long periods of time. Staff to check skin BD and report any redness or excoriation to RN in charge. Pressure relieving devices to be obtained as required. Air mattress, Gel cushion Equagel Protector Cushion to wheelchair or recliner at all times.

Floor sensor mat required.

Skin Condition

CONDITION

Medical conditions Other details of other past and present conditions - i.e. dates, severity, surgical procedures, tests, etc.

Type of diabetes

Dementia Alzheimer's dementia with psychotic features (November 2017 .) Anxiety. Depression. Insomnia. Visual Hallucinations. Atrial fibrillation, Permanent pacemaker. Hypertension. Chronic Kidney Disease. Oedema sec to CKD. Chronic pain. Osteoarthritis of Joints. Abnormalities of Gait and Mobility. Reduced Dynamic Balance. Non-Ambulant. Falls. Urinary and Faecal Incontinence. Urinary tract infections. Constipation. Poor appetite => Weight Loss=> At risk of malnutrition. Fractured L) NOF (Nov 2018) Left below knee DVT.

NIA NB: staff must note foot care, dietary considerations, regular eye check-ups, skin care and specialist review, in otller relevant assessments when Diabetes is diagnosed.

Past/present skin conditions of significance:

Nutrition/hydration status Any relevant systemic/topical medications impacting on condition of skin Potential skin integrity issues

© Leecare Solvtions Pfy. Ltd

Printed By : L':.':Yi.':.'J Keys [Quality Manager/ on 19102/2019 12:23 PM

ISSUES

Alzheimer's dementia with psychotic features (November 2017.) Permanent pacemaker. Chronic Kidney Disease. Oedema sec to CKD. Reduced Dynamic Balance. Non-Ambulant. Falls. Urinary and Faecal Incontinence. Urinary tract infections. Constipation. Poor appetite=> Weight Loss =>At risk of malnutrition. Ory flaky skin. Poor requires staff assistance to maintain Refer to medication chart

Alzheimer's dementia with psychotic features (November 2017.) Permanent pacemaker. Chronic Kidney Disease. Oedema sec to CKD. Reduced Dynamic Balance. Non-Ambulant. Falls. Urinary and Faecal Incontinence.

of 4

MRA.0003.0001.1196

Skin Assessment

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Facility Name: Green~y Gardens Room No UNADMITIED UR No/ACS ID.-DOB • Admission NOT ADMITIED YET

Report created on: 26/01/2019 6:40 AM by Tania Nanda [Registered Nurse Division Urinary tract infections. Constipation. Poor appetite => Weight Loss => At risk of malnutrition. Dry flaky skin.

PROBLEMS

Skin Problems Bruises, Flaky/dry skin

Skin Maintenance

INTERVENTIONS

Skin care requirements

How many times does this resident need to be repositioned in 24 hrs?

Specify times this person is to be repositioned within a 24 hr period

Emoll ient or barrier c ream

How many times does this need to be applied in 24 hrs?

Specify times this needs to be applied within a 24 hr period

Other skin maintenance measures - e.g. stomacare

@ Leecare Solutions Pty. Ltd

Printed By : C.':vi':.'J Keys [Quality Manager) on 19/0212019 12:23 PM

Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight. Ensure skin does not remain in contact with moisture for long periods of time. Staff to check skin BO and report any redness or excoriation to RN in charge. Pressure relieving devices to be obtained as required. Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight.

Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight.

: Moisturizer to be applied after hygiene care and prior to settling. Barrier cream to be applied post episodes of incontinence as required

BO /PRN : Moisturizer to be applied after hygiene care and prior to settling. Barrier cream to be applied post episodes of incontinence as required

Staff to check skin integrity BO. Report any changes to skin, such as swelling I breaks I skin tears I redness I skin discoloration I heat or warmth to area - To RN/EN. Ensure correct well-fitting footwear worn. Wash/dry between toes thoroughly. Sunscreen applied when going outside

PRESSURE AREAS I PRESSURE WOUND MANAGEMENT Inspect skin integrity BO Staff report to RN if any compromise to the skin integrity. Ensure side to side re-positioning and PAC as directed Ensure appropriate

of 4

lee Solutions

MRA.0003.0001.1197

Skin Assessment

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COi DAGE Facility Name Greenway Gardens Room No UNADMITIED UR No./ACS ID. -

DOB - Admission- NOT ADMITTED YET

Report created on: 26/01/2019 6:40 AM by Tania Nanda [Registered Nurse Division use of pressure relieving devices as directed

Staff to report any strike through on dressing, discomfort, increased pain and or odour. Refer to wound assessment and wound management plan as required Air matress in place. Staff to ensure photo is taken during the dressing change- to monitor wounds closely.

OEDEMA MANAGEMENT - (Refer to complex care-Oedema management) Staff are to elevate lower limbs when sitting out of bed I in chair Apply Venosan medium compression garment to lower legs from toes to knee application. Staff are to apply the Venosan medium compression garment in the AM post ADLs and remove in the PM/prior to settling. Apply moisturiser to lower legs daily post showering Report to the RN I Team Leader any increase in swelling and if there is any skin breaks I redness I skin discoloration I heat or warmth to the area I fluid seeping from legs.

RISK OF SKIN TEARS AND BRUISING TO LIMBS DUE TO AT RISK OF FALLS Staff are to ensure that Giovanna's mobility and transfers are attended as per the functional assessment and that all bruising and skin tears are reported to the RN and protected from further injury. Keep skin covered with clothing I protected as able appropriate to weather. Remove any sharp edges i.e. furniture to reduce risk of injury and keep skin moisturised where possible.

Foot care - e.g. to do with peripheral neuropathy I diabetes

Nail care requirements

emolient daily

Staff to check nails daily & clean and trim fingernails weekly and as required, toenails to be attended to by podiatry as per facility schedule and as required.

JBI References re management

IC> Leecare Solutions pty. Ltd

Printed By : l°:.°.:\if.·:."J Keys [Quality Manager/ on 1910212019 12:23 PM of 4

MRA.0003.0001 .1 198

Skin Assessment

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Facility Name \.OI OAGE

Greenway Gardens Room No· UNADMITTED UR No./ACS 10-DOB· dmission: NOT ADMITIED YET

Report created on: 26/01/2019 6:40 AM by Tania Nanda [Registered Nurse Division

JBI REFERENCES RE SKIN I PRESSURE AREA CARE I PRESSURE ULCER PREVENTION I STOMA CARE I PSORIASIS I RISK I TOPICAL

REFERENCE: Pressure Area Care - Prevention: http:llconnect.jbiconnectplus.org/ViewPdf.aspx?0=3615& 1 =1 REFERENCE: Pre$sure Area Care- Management : http://connect.jbiconnectplus.orgNiewPdf.aspx?0=3608&1=1 REFERENCE: Pressure Ulcers (Prevention)- Support Surfaces: http:l/connect.jbicxmnectplus.org/ViewPdf.aspx?0=255&1=1 REFERENCE: Skin Tears- Prevention : hltp:llconnect.jbiconnectp/us.orglViewPdf.aspx?0=1659&1=1 REFERENCE: Pressure Ulcers - Nutrition: http://connect.jbiconnectplus.org/VlewPdf.aspx ?0=4022&1=1 REFERENCE: Psoriasis: Clinician information: http:llconnect.jbiconnectplus.org/ViewPdf.aspx?0=1585& 1=1 REFERENCE: Psoriasis - Treatments: http://connect.jbiconnectplus.org/ViewPdf.aspx?0=1586& 1=1 REFERENCE: Risk Assessment for Pressure Ulcers in Older people in Community Settings : http:llconnect.j biconnectplus.org/ViewPdf.aspx?0=4009& 1=1 REFERENCE· Stoma - Assessment and Care : http://connect.jbiconnectplus.orgN1ewPdf.aspx?0=3637& 1= 1 REFERENCE: Topical Skin Care : http://connect.jbiconnectp/us.org/ViewPdf.aspx?0=4209&1=1 REFERENCE: Topical Medications : http:/lconnect.jbiconnectplus.orgMewPdf.aspx?0=3568&1=1

© Leecare Solutions Pty. Lid

Printed By : :.·~ .. j,if.·~.J Keys {Quality Manager] on 19/0212019 12:23 PM of 4

MRA.0003.0001 .1 199

Skin Assessment

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Facility Name Green~_Room No: UNADMITIED UR No/ACS ID:-DOB ~dmission · NOT ADMITTED YET

Report created on: 22/11/2018 8:11 AM by Karen Jackson [Registered Nurse]

Pressure Ulcer Risk

NORTON SCORE

General physical condition Mental state Activity Mobility Incontinence Norton score

Poor Confused Chair Bound Immobile Doubly 8

PRESSURE ULCER PREVENTION

Pressure ulcer prevention strategies for this person

Pressure relieving devices to be used Other

Sensor Mat usage details - past and current

Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight. Ensure skin does not remain in contact with moisture for long periods of time. Staff to check skin BO and report any redness or excoriation to RN in charge. Pressure relieving devices to be obtained as required. Air mattress. Gel cushion Equagel Protector Cushion to wheelchair or recliner at all times.

Floor sensor mat required.

Skin Condition

CONDITION

Medical conditions Other details of other past and present conditions - i.e. dates, severity, surgical procedures, tests, etc.

Type of diabetes

Dementia Alzheimer's dementia with psychotic features (November 2017.) Anxiety. Depression. Insomnia. Visual Hallucinations. Atrial fibrillation, Permanent pacemaker. Hypertension. Chronic Kidney Disease. Oedema sec to CKD. Chronic pain. Osteoarthritis of Joints. Abnormalities of Gait and Mobility. Reduced Dynamic Balance. Non-Ambulant. Falls. Urinary and Faecal Incontinence. Urinary tract infections. Constipation. Poor appetite=> Weight Loss=> At risk of malnutrition.

N/A NB: staff mvst note foot care, dietary considerations, regvlar eye check-1.1ps, skin care an<J specialist review. in other relevant assessments when Diabetes is diagnosed.

Past/present skin conditions of significance:

Nutrit ion/hydration status Any relevant systemic/topical medications impacting on condition of skin Potential skin integrity issues

© Leeca~ So/1.1tions Pty. Ltd

Printed By : Cji!::JKeys [Quality Manager} on 19/02/2019 12:22 PM

ISSUES

Alzheimer's dementia with psychotic features (November 2017.) Permanent pacemaker. Chronic Kidney Disease. Oedema sec to CKD. Reduced Dynamic Balance. Non-Ambulant. Falls. Urinary and Faecal Incontinence. Urinary tract infections. Constipation. Poor appetite => Weight Loss => At risk of malnutrition. Dry flaky skin. Poor requires staff assistance to maintain Refer to medication chart

Alzheimer's dementia with psychotic features (November 2017.) Permanent pacemaker. Chronic Kidney Disease. Oedema sec to CKD. Reduced Dynamic Balance. Non-Ambulant. Falls. Urinary and Faecal Incontinence. Urinary tract infections. Constipation. Poor appetite=>

Page 1 of 4

MRA.0003.0001 .1200

Skin Assessment

lee Solutions

-~c le~• t- 1 ~· "' C'1ov1 L 8' ''1A CC1l DAGE

Facility Name· Green~ Room No: UNADMITIED UR No./ACS ID·-DOB· --Admission: NOT ADMITTED YET

Report created on: 22111/2018 8:11 AM by Karen Jackson [Registered Nurse) Weight Loss =>At risk of malnutrition. Dry flaky skin.

PROBLEMS

Skin Problems Bruises, Flaky/dry skin

Skin Maintenance

INTERVENTIONS

Skin care requirements

How many times does this resident need to be repositioned in 24 hrs?

Specify times this person is to be repositioned within a 24 hr period

Emollient or barrier cream

How many times does this need to be applied in 24 hrs?

Specify t imes this needs to be applied within a 24 hr period

Other skin maintenance measures - e.g. stomacare

© Leecare Solutions pty. Ltd

Printed By : [~~jii.~~~! Keys [Quality Manager} on 19/021201 9 12:22 PM

Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight. Ensure skin does not remain in contact with moisture for long periods of time. Staff to check skin BO and report any redness or excoriation to RN in charge. Pressure relieving devices to be obtained as required. Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight.

Staff x 2 provide physical assistance with PAC and repositioning 2-3/24 during the day and staff x 2 provide physical assistance with PAC and re-positioning 4/24 overnight.

: Moisturizer to be applied after hygiene care and prior to settling. Barrier cream to be applied post episodes of incontinence as required BD/PRN : Moisturizer to be applied after hygiene care and prior to settling. Barrier cream to be applied post episodes of incontinence as required

Staff to check skin integrity BO. Report any changes to skin, such as swelling I breaks I skin tears I redness I skin discoloration I heat or warmth to area - To RN/EN. Ensure correct well-fitting footwear worn. Washldry between toes thoroughly. Sunscreen applied when going outside

PRESSURE AREAS I PRESSURE WOUND MANAGEMENT Inspect skin integrity BO Staff report to RN if any compromise to the skin integrity. Ensure side to side re-positioning and PAC as directed Ensure appropriate use of pressure relieving devices as directed

Page 2 of 4

lee Solutions

MRA.0003.0001.1201

Skin Assessment

~ ~- tic~• .. a'T'le G1ova a 8' JDP.

Facihty Name Greenw~_Room No UNADMITIED UR No./ACS ID DOB ~dmission NOT ADMITIED YET

-

c.OIDAGE

Report created on: 22/11/2018 8:11 AM by Karen Jackson [Registered Nurse]

Staff to report any strike through on dressing, discomfort, increased pain and or odour. Refer to wound assessment and wound management plan as required

OEDEMA MANAGEMENT - (Refer to complex care-Oedema management) Staff are to elevate lower limbs when sitting out of bed I in chair Apply Venosan medium compression garment to lower legs from toes to knee application. Staff are to apply the Venosan medium compression garment in the AM post ADLs and remove in the PM/prior to settling. Apply moisturiser to lower legs daily post showering Report to the RN I Team Leader any increase in swelling and if there is any skin breaks I redness I skin discoloration I heat or warmth to the area I fluid seeping from legs.

RISK OF SKIN TEARS AND BRUISING TO LIMBS DUE TO AT RISK OF FALLS Staff are to ensure that Giovanna's mobility and transfers are attended as per the functiona l assessment and that all bruising and skin tears are reported to the RN and protected from further injury. Keep skin covered with clothing I protected as able appropriate to weather. Remove any sharp edges i.e . furniture to reduce risk of injury and keep skin moisturised where possible.

Foot care - e.g. to do with peripheral neuropathy f diabetes

Nail care requirements

emolient daily

Staff to check nails daily & clean and trim fingernails weekly and as required, toenails to be attended to by podiatry as per facility schedule and as required.

JBI Referenc.es re management

JBI REFERENCES RE SKIN I PRESSURE AREA CARE I PRESSURE ULCER PREVENTION I STOMA CARE I PSORIASIS I RISK I TOPICAL

REFERENCE: Pressure Area Care - Prevention: http.J/connect.Jbiconnectplus.org/ViewPdf. aspx ?0=3615& f = 1 REFERENCE: Pressure Area Care- Management : http.Jlconnect.fbiconn&etplus.orgNiewPdf.aspx?O=J608&1=1 REFERENCE: Pressure Ulcers (Prevention)- Support Surfaces.· http:llconnect.jbiconnectp/us.orgNiewPdf.aspx?0=255&1=1

© Leecare Solutions Pty. ltd

Printed By : L~jij~J Keys (Quality Manager] on 19/0212019 12:22 PM Page 3 of 4

lee Solutlons

Skin Assessment

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Facility Name. Green~s Room No. UNADMITIEO UR No /ACS ID -DOB·~ Admission· NOT AOMITIED YET

Report created on: 22111/2018 8:11 AM by Karen Jackson [Registered Nurse] REFERENCE: Skin Tears- Prevention: http://connect.jbiconnectplus.orgNiewPdf.aspx?0=1659&1=1 REFERENCE: Pressure Ulcers · Nutrition: http://connect.jbiconnectplus.orgNiewPdf.aspx?0=4022&1=1 REFERENCE: Psoriasis: Clinician information: http://connect.jbiconnectplus.orgNiewPdf.aspx?0=1585& 1=1 REFERENCE: Psoriasis - Treatments: http:llconnect.jbi<XJnnectplus.orgNiewPdf.aspx?O= 1586& 1 =1

MRA.0003.0001.1202

COLOAGE

REFERENCE: Risk Assessment for Pressure Ulcers in Older people in Community Settings : http:llconnect.jbiconnectplus.org/ViewPdf.aspx ?0=4009& 1=1 REFERENCE. Stoma -Assessment and Care : http:llconnect.jbiconnectplus.orgNiewPdf.aspx?0=3637&1=1 REFERENCE: Topical Skin Care : http:llconnect.jbiconnectp/us.org/ViewPdf.aspx?0=4209& 1=1 REFERENCE: Topical Medications : http:llconnect.jbiconnectplus.orgNiewPdf.aspx?0=3568&1=1

© Leecare Solutions pty. Ltd

Printed By : r:::vi·:."J Keys [Quality Manager) on 19/0212019 12:22 PM Page 4 of 4

lee Solutions

Drug allergies

Wound Diagram

J

MRA.0003.0001.1203

Wound I Skin Management Plan and Evaluation

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Facility Name· Greenw~_Room No· UNADMITIED UR No./ACS ID: - If E~ DOB: ~dmission : NOT ADMITTED YET

Report created on: 28/0312019 5:13 PM by Jason Kim (Registered Nurse)


ALLERGIES Morphine

Sacral pressure area 08/01/201912:37:00 PM

Sacral break 18/12/2018 8:26:03 AM

Sacral area 28/12/2018 12:44:00 PM

© Leecare Solutions Pty. Ltd

Printed By : Fiona van den Berg {Administration Manager] on 28/09/2019 3:04 PM Page 1 of 4

MRA.0003.0001.1204


lee Resident Name Giovanna BlJDA ~-11 ..

M --..111. . k enaroc Solutlons Facility Name. Greenw~_Room No: UNADMITIED UR No.!ACS IO·~lfE~

DOB. ~dmission. NOT AOMITIEO YET

Sacral Wound 26.1.19 26/01/2019 6:42:36 AM

Report created on: 28/03/2019 5:13 PM by Jason Kim [Registered Nurse)

Wound & Skin (acute) Management Plan & Evaluation - Record: 4919724

Date of Wound Position Description Resulting From

Surrounding Skin Details Dry skin Exudate type Amount

Odour details Nil odour

Goal of interventions I wound healing Details of Primary and Secondary Dressing

DESCRIPTION OF WOUND 20/1112018 buttocks ( coccyx ) Broken Pressure area. Pressure

Yes Haemopurulent Light

Yes

INTERVENTIONS To promote healing and prevent infection. Packed with gauze and betadine

Mepilex border.

Shower Cleanser details i.e. saline, in shower Frequency of dressing change and other details Check daily to ensure dressing in place.717 or PRN

WOUND HEALING STATUS Select a date here to Indicate this latest healing status evaluation Reason for review Details Other details of evaluation

© Leecare Solutions Ply. Ltd

2710112019

Routine review, Change of care needs required Epitheliasing - pink

Printed By : Fiona van den Berg [Administration Manager] on 28f0912019 3:04 PM Page 2 of 4


MRA.0003.0001.1205

M~ .... . k enaroc lee Solution$ Facility Name: Green~ Room No: UNADMITTED UR No./ACS 1o ·••llFE~

DOB --Admission : NOT ADMITTED YET

Report created on: 28/03/2019 5:13 PM by Jason Kim [Registered Nurse]

Agatha attended facility today to pick up clothing for Giovanna. Asked after Giovanna and she stated that she was still very unwell. Received a call from son Ross and MPOA stating that Giovanna is to be discharged from Greenway gardens due to length of stay in hospital and then rehab. Requested that Ross put all details in writing. Ross happy with all explanations.

By Karen Jackson (Registered Nurse] on 1110212019 16:21

Record ID: 4919724 RESOLVED (4919724) 28/03/2019 5:13 PM By: Jason K im (Registered Nurse) (BATCH -5121311)

Wound & Skin (acute) Management Plan & Evaluation - Record: 4913616

Date of Wound Position Description other resultant type description

Surrounding Skin Details

Normal skin Exudate type Amount

Wound Stage

DESCRIPTION OF WOUND 16/1112018 L) side of hip Post surgical wound Fractured NOF

Yes None None

1 - non blanchable erythema of intact skin, suture or clip line Yes

Odour details

Nil odour Yes

INTERVENTIONS Goal of interventions I wound healing Details of Primary and Secondary Dressing Cleanser details i.e. saline, in shower Frequency of dressing change and other details

100% wound healing Opsite post OP visible Normal saline in 2 weeks post OP

WOUND HEALING STATUS Select a date here to indicate this latest healing status evaluation Reason for review Other details of evaluation

© Leecare Solutions Pty. Lid

06/12/2018

Routine review

Printed By : Fiona van den Berg {Administration Manager] on 2810912019 3:04 PM Page 3 of 4

lee Solutions

MRA.0003.0001.1206


Facility Name

Resident Name G1ovarm;:i BUDA '!... •. ~ ....

Menarock Greenw~.Room No: UNADMITTED UR No./ACS ID: - IF E-~

DOB: ~dmission . NOT ADMITTED YET

Report created on: 28/0312019 5:13 PM by Jason Kim [Registered Nurse)

SB GP today, staples noted. Nil discharged noted. Yellowish discoloration around the wound area. Monitor. Alternate staples out 24111f18 and all remaining to be removed 25f11/18. 25f11/2018 -All staples removed by Night in charge nurse. Wound area cleaned and healed sufficiently. Nil sign of infection. No opened area. Primapore and Opsite Flexifix applied for protection. Resolved

Record ID: 4913616

RESOLVED (4913616) 11/12/2018 12:14 PM By : Karen Jackson (Registered Nurse) (BATCH· 4952029)

© Leecare Solutions Ply. Ltd

Printed By : Fiona van den Berg [Administration Manager] on 28/0912019 3:04 PM Page 4 of 4

Skin Assessment - Aged Care Royal Commission

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Transcript of Skin Assessment - Aged Care Royal Commission