The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)
a. "Can you easily change your position?"
b. "Do you have sensitivity to heat or cold?"
c. "How often do you need to use the toilet?"
d. "What medications do you take?"
e. "Is movement painful?"
f. "Have you ever fallen?"
ANS: A, B, C, E
Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, she can protect herself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with painful movement will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.
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