Skin

Skin can reveal changes in perfusion, pressure exposure, moisture burden, infection, vascular status, or a medication reaction before the patient describes a problem. A comprehensive skin assessment is a head-to-toe description of the patient's current tissue status: temperature, color, moisture, turgor, and integrity, including any existing breakdown. This assessment is different from a pressure-injury risk assessment. Inspection and palpation describe injury that is present; a tool such as the Braden Scale estimates the likelihood of future injury. Most acute-care settings repeat the skin assessment when the patient arrives on the unit, at least daily, and at transfer or discharge. Document the findings in a way that permits comparison, and report new or worsening abnormalities. The LPN/LVN contributes focused skin observations, data collection, monitoring, documentation, and reporting within the assignment, state scope of practice, and facility policy. This focused role does not replace the RN's initial comprehensive nursing assessment where that responsibility is assigned to the RN. On the current NCLEX-PN test plan, skin findings are integrated with clinical judgment, prioritization, safety, and coordinated care rather than tested as an isolated...