Correctional Nurse Goals for 2015: Expand Your Network!

2015 goalsIt is pretty easy to feel isolated in correctional nursing practice. We work in a mostly unacknowledged specialty with a patient population that many think do not deserve good nursing care. We can easily feel as vulnerable and marginalized as our patient population. Combine with that the ‘push back’ we can sometimes get from the culture of incarceration (pressure to be less caring and concerned for the well-being of our patients) and it is easy to see why many in our practice settings feel overwhelmed and underappreciated.

That’s why I recommend a goal to network with others in your specialty this year. Developing a network of like-minded nurses who desire to make a difference in their practice in the criminal justice system can be just the ticket to improve your outlook and revitalize your correctional nursing career. Here are a few ideas for how to increase your network in 2015:

Go Local

Nothing beats a face-to-face chat to regain perspective and feel supported. Are there local opportunities to meet with other correctional nurses? For example, does your state prison system host any activities or events that bring nurses together? How about the state nursing association? Some states have specialty practice forums that may include correctional nursing.  Consider a neighboring county jail.  Suggest forming a journal club or meet-and-greet where correctional nurses can gather and develop relationships.

Go National

Another way to network with correctional nurses is to attend a national correctional conference. Your facility management may be involved in the American Correctional Association or the American Jail Association. Both have conferences that are attended by health care staff. See if there may be funding for your attendance this year. (TIP: Before requesting funding, research the event and suggest ways some of the presentation content may be applied to make improvements in your facility).

Other excellent national conference to attend are any by the National Commission on Correctional Health Care (NCCHC) or the American Correctional Health Services Association (ACHSA). These conferences are solely for correctional health care professionals and are attended by many correctional nurses. Opportunities for networking abound during exhibit hours, sessions, and round table discussions. Additionally, regional conferences are offered by ACHSA chapters in California/Nevada, Oregon, and the  Southeast Region.

When attending a conference, be careful to mingle with people you do not know and sit at tables with others you would like to meet. If you attend with a group, make plans to attend different sessions and compare notes rather than traveling about the conference as a group. This will expand your opportunities to meet new people.

Go Social

Social networking is now available through social media outlets such as Facebook and LinkedIn. Both of these platforms have correctional nursing groups were nurses in our specialty share concerns and get advice or direction on issues. Consider connecting with other like-minded nurses working in the criminal justice system by joining these groups:

Correctional Nursing on Facebook

Correctional Nursing on LinkedIn

I hope you expand your correctional nursing connections this year and develop a personal network of fellow nurses. We need encouragement and support to recharge our careers, enhance professional practice in our specialty, and improving health care for our unique patient population!

What will you be doing this year to network with other correctional nurses? Share your ideas in the comments section of this post.

Photo Credit: © dolphfyn – Fotolia.com

Correctional Nurse Goals for 2015: Get Certified!

Hand underlining 2015 Goals with red marker, business conceptWhat, you say? Take an exam in 2015? Do I really want to do that? Are these questions running through your mind at the idea of getting a certification this year? Here are some thoughts on why you should consider becoming certified in your specialty this year.

I Have a Nursing License Already

You might be asking yourself – why do I need certification when I have a nursing license? Licensure is definitely required to provide our level of health care. It is a governmental requirement for practice that protects the public from incompetent practitioners. Specific educational requirements, such as the amount of practical hours of training, are often a part of the State Practice Acts governing entry level into the profession.

Certification, on the other hand, is voluntary, non-governmental, and not required to enter into nursing practice. It recognizes an individual’s advanced knowledge and skill beyond initial licensure. Most certification programs require a minimum number of hours of practice in the specialty along with a written certification exam.

Worth the Effort?

Is there value to all the effort it will take to gain certification? The American Board of Nursing Specialties completed research in this area and found these 5 components of certification value. Which ones resonate with your professional values?

Professional Recognition: Probably first and foremost is professional recognition among employers, peers, and consumers. Certification denotes a proven knowledge base and documented experience in a given specialty. I experienced this myself as a consumer this past year when my husband prepared for a total hip replacement. The orthopaedic surgeon looked young to me…a problem I have a lot these days as I am getting older (!). While in the waiting room for the consultation visit, I was contemplating asking that uncomfortable question about how many surgeries of this type he had completed. However, just in time, my eyes fell on a framed certificate of board certification with the American Academy of Orthopaedic Surgeons. That was comforting…as was our conversation with him shortly afterwards where he explained the procedure and volunteered his frequency of performing it. By the way, my husband is doing very well after the surgery and we are very happy with the results.

Professional Credibility: Credibility is another component of certification value. This was important to me when I became a correctional nurse educator 10 years ago. If I was going to be orienting and educating nurses in the specialty, they needed to know that what I was saying was credible and that I knew what I was talking about. One way to do this is through certification. I started on my journey to the basic CCHP certification the first year I was a correctional nurse. Actually, I brought others along with me by starting certification study groups in any facility with interest. We had over 20 people sit for the certification exam after we all studied together. It was exhilarating and I recommend this as an idea for you. Start a study group in your facility and go through the process together.

Sense of Accomplishment: It is easy to see how you would have a sense of accomplishment through successful completion of a specialty certification exam. It can be hard work and you deserve congratulations at the finish line.

Knowledge Validation: Certification validates basic knowledge for the particular specialty – above and beyond initial general professional knowledge.

Marketability: All these outcomes also mean marketability. Certification means you will stand out in a crowd of resumes vying for a particular position. It not only speaks to your knowledge but to your motivation and perseverance in the specialty. Someone who is only passing through is not going to bother with certification. Someone who is not interested in their career is not going to get certified. Someone who is not willing to diligently pursue excellence is not going to be certified. You get the picture. Certification says you are someone who is motivated to do a good job in our specialty.

I hope I have convinced you to consider certification in correctional nursing in 2015. Here are some earlier posts that can help you create an action plan to prepare for certification:

Correctional Nurse Certification Options

The Certification Journey #1: Where Do We Start?

The Certification Journey #2: Determining What to Study

The Certification Journey #3: Creating a Study Plan

The Certification Journey #4: Rule the Day

What do you think about professional certification? Share your thoughts in the comments section of this post.

Photo Credit: © dizain – Fotolia.com

Correctional Nurse Goals for 2015: One Change that Makes All the Difference!

2014 end and 2015 way signsI love the start of anything new, don’t you? That’s why a new year and a brand new calendar can really brighten my spirits. Although I am not one to make resolutions, I am a big goal-setter. Do you have goals for your correctional nursing practice for 2015?

The Little Story that Changed My Life

Here is a short story I heard years ago that changed my life for the better. I try to remember it several times a year to help center my mental perspective. Have you heard a version of this before?

Two workman were approached by a bystander on a major construction site. They were both performing the same job and were asked what they were doing. The first one said, “What does it look like I’m doing? I’m laying brink.” The second one looked up from where he was crouched and off toward the sky. His response? “I’m building a cathedral.”

Two men doing the same job yet from a very different mental perspective. Which one do you think went home that night feeling like he was doing something that mattered? Which one left the worksite feeling satisfied with his lot in life?

What might you tell a visitor to your work place if they asked you what you do as a correctional nurse? Would you respond like the first workman and say “I pass pills and take sick call”? Or, would you say, “I optimize health, prevent illness and injury, and alleviate suffering.” That last answer comes from the definition of correctional nursing, by the way.

It is All About Perspective

Yes, both those workman were doing the same thing and both had an honest response. And, both the options for describing your work as a correctional nurse would be true…..but what a difference in perspective. The first perspective is of activity while the second perspective is about purpose. Thinking about purpose in our day-to-day work provides the meaning and satisfaction that makes it worth the extra effort.

I have often said that most of us become nurses to help those in need and that there is not a needier patient population than inmates. So, the real effort in the correctional specialty is often to mentally balance the patient-focused purpose of our work with the ever-present struggles of a needy patient population in a challenging environment. It can really get you down.

Mind Your Mind

So, that comes to my first suggested goal for 2015 – Mind Your Mind. What I mean by that is to keep tabs on your attitude toward your work. This is an important goal no matter where you work but it can be a real battle in the correctional environment. In case you haven’t noticed, jails and prisons are not happy places. Most people, including some of our officer colleagues (!), don’t want to be there. Hanging around with criminals all day can be a real downer. Plus, it is always necessary to be on guard for possible physical, emotional, or mental harm. No wonder you are exhausted as you walk out the sally port to the parking lot.

Take Action Right Now on This Goal

I hope you are convinced that keeping a positive mental perspective is a worthy goal for your correctional nursing practice this year. However, this quote says it all:

“A goal without a plan is just a wish” – Antoine de Saint-Exupery

So, here are some action steps to start your “Mind Your Mind” plan:

  • Establish a way to regularly remind yourself of your professional purpose. Maybe you can have it on a post-it note on your car dashboard so you can recite it on the way to work in the morning.
  • On your walk from the medical unit to the facility exit, see if you can list all the ways that you improved health, prevented illness and injury, and alleviated suffering during your shift.
  • On your way home, mentally close the door on all that is going on at the facility so you can truly engage with family and friend and rest during your time away from work.
  • Get some form of regular mild exercise like walking or biking to help your mental perspective.
  • Develop a plan to get the rest you need to be both alert and in a good mental perspective when you are at work.

This one change can make all the difference – changing your perspective. Will you be building a cathedral or merely laying bricks in your correctional nursing practice in 2015? I hope you will join me in cathedral building!

Revitalize your correctional nursing practice by reading the Essentials of Correctional Nursing book. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 and shipping is free.

2014 in Review

 

FireworksThanks for visiting Essentials of Correctional Nursing today. We have been on line almost three years, with posts nearly every week. Our mission is to provide interesting and practical tips regarding the best practices in correctional nursing. This blog and our book, Essentials of Correctional Nursing are resources for nurses practicing in correctional settings, especially those who are or are pursuing certification in the specialty. So how did we do this year?

Readership increased 28% this year over last. In November we reached an all-time high of 140 visits to our blog on average every day. Although we have readers from 146 countries, the majority are located in the U.S., Canada, the U.K. and Australia. By the way, the biennial international conference on correctional nursing takes place this next year in Canada (October 7-9, 2015) and presentation proposals are being accepted now. This is a great conference and the nurses from other countries are fascinating!

All of our posts (135 and growing weekly) can be accessed in the archive by using the search field or by clicking on the categories of interest listed on the right side of the page. This year our posts dealt with subjects concerning Nursing Practice, Populations with Special Health Needs, and Professional Issues. The following is a brief descriptive summary.

Nursing Practice: We spent nine weeks exploring the problem of misuse of alcohol and/or drugs. Identifying, monitoring and managing withdrawal symptoms are among the most common features of correctional nursing practice. In this last year we have seen how prescription drug misuse is fueling the use of heroin especially in urban areas across the states. We also touched on nursing practices to prevent drug diversion. Nursing assessment and intervention to manage withdrawal in advance of symptoms goes a long way toward preventing morbidity and mortality while in custody.

We devoted six posts to the specifics of nursing sick call, another signature of correctional nursing practice. Sue Smith, author of the chapter on sick call in Essentials of Correctional Nursing says that “…sick call can be a thing of beauty” allowing registered nurses to practice to the fullest extent of their knowledge and skill (page 304). Even more importantly it is the primary means available to inmates to achieve relief from troubling symptoms and pain and fulfills the principle of daily access to care required by the constitution.

Other areas of nursing practice that were discussed this year are also unique to correctional nursing. These included tips on how to manage difficult patients in the nursing encounter, assessment of skin conditions (most frequent complaint in nursing sick call), and the nursing care of patients on hunger strike. Lastly this fall we covered Ebola, along with everyone else. We hope you found the resources on Ebola provided from other correctional systems helpful and timely.

Populations with Special Health Needs: An often used phrase in correctional settings is “firm, fair and consistent” emphasizing that disturbances or other security risks are minimized when all inmates are treated the same. While it is true that perceived unfairness leads to complaints and unrest, the reality is that the health needs of inmates are not the same and require individualized attention. Our posts looked at unique and nuanced approaches to the nursing care during incarceration of women (a series of eight posts), youth (a series of four posts), veterans and the deaf or hearing impaired. Another feature unique to correctional nursing is that we are generalists and must be able to provide appropriate and responsive health care for patients with widely varied needs.

Professional Issues: The National Commission on Correctional Health Care (NCCHC) published new accreditation standards for prisons and jails that went into effect in October. One of the changes was to require peer review of nursing practice. To assist nurses in developing and participating in peer review programs, four posts were devoted to defining and describing peer review, suggesting ways to implement peer review and providing examples of peer review processes. We expect that this requirement will apply to nurses in juvenile settings as well when NCCHC revises these standards in 2015.

Delegation is the most popular subject of all our posts so we devoted another four posts to this topic. We discussed the principles as well as the most common barriers to delegation. We also reviewed communication skills and explored organizational models that facilitate delegation and supervision. These posts also coincided with publication of Nurses Scope of Practice and Delegation Authority, a white paper on the NCCHC website which addresses the assignment of nursing personnel in correctional facilities.

Correctional health care as it is provided today has been profoundly shaped by the law; more so than any other field in health care delivery. The legal parameters of correctional nursing were explored in three posts. Defining and establishing working environments that support professional nursing practice was suggested as one sure way to reduce risk of malpractice or other legal intervention. Grievances are another unique feature of the correctional setting and health care is a frequent source of inmate complaints. Since grievances are a precursor for litigation one of our posts provided tips and techniques to make best use of the complaint process. It also had the most comments from readers. We reviewed a study of nurses’ professional liability claims in another post that suggested the following ways to reduce liability:

  • Practice nursing consistent with state law and organizational policy.
  • Communicate professionally, accurately, respectfully and be inclusive, complete, appropriate and timely.
  • Maintain clinical competencies relevant to the population served.
  • Advocate for patients to prevent harm.

While there is a lot to write about in correctional nursing it would be great to know if we are covering the subjects you are most interested in. Take a minute to share your suggestions by replying in the comments section of this post. Your ideas will inspire us to write in 2015 so we hope to hear from you soon. In the meantime…

Have a Safe and Prosperous New Year!

It’s not too late to order another copy of the Essentials of Correctional Nursing. Get $15 off and free shipping by ordering directly from the publisher using promotional code AF1209.

 Photo credit: © Roman Dekan – Fololia.com

Improving productivity of sick call

SchokoladeProductivity of nursing sick call was the subject of last week’s post. Meeting the basic principles of access to care and the right to a clinical judgment requires keeping up with sick call demand. When nurses and managers allow requests for health care attention to go unattended for more than a day they are ignoring these principles and their failure to act puts patients at risk of harm. Sometimes it is hard to picture the cumulative effect of not keeping up with sick call demand. An example of not keeping up with productivity requirements is depicted humorously in the chocolate factory scene on the I Love Lucy show.

How many patients should a proficient registered nurse be able to see in sick call in an hour? This is an important question to consider because sick call must be appropriately staffed to meet demand. Also because sick call is not performed in other settings nurses do not have experience from other settings to inform their own performance expectations. Ten experienced correctional nurses responded to this question. Collectively they have nearly 300 years of experience providing health care in the correctional setting and equally represent jails and prisons of all sizes, in every part of the country. The consensus was on average, seven patients per nurse per hour. Remember this is an average and not an absolute. Factors that contribute to variation from this average include gender (more time is required to see women), health status (patients with complex health problems vs simple concerns), whether requests are triaged first (when not triaged first, all patients are seen even those with scheduling or administrative issues), and location (privacy and availability of equipment or supplies).

Seven patients per hour equates to 8.5 minutes per patient. Referring to the example from last week one nurse could expect to spend three hours each day seeing an average of 21 patients who have requested health care attention for problems that require a nursing assessment. There is also an average of 13 urgent walk-ins that require another couple hours of nursing time. If sick call is taking longer than this or there is a back log, critical examination of the process should identify prospects for improved productivity. Here are some suggestions from our experienced nurse colleagues.

Build competency: It takes time to develop nursing sick call skill. A newly hired nurse may see an average of three or four patients an hour and so staffing should take this into consideration. It is reasonable to expect nurses to have a fund of knowledge sufficient to conduct a focused head to toe assessment but they are not likely to have developed these practice skills in a high volume, primary care setting. An approach to building these competencies is to establish a teaching/mentoring relationship with an experienced nurse (or nurse practitioner) and see patients together. Another approach is to team a nurse with a provider and run sick call and primary care clinic concurrently. This later suggestion may require more elaboration but the idea is that the nurse has more assistance and collaboration available when addressing patient needs so that the number of encounters necessary to address a problem can be reduced.

Eliminate waiting: Ask for help to eliminate time lost waiting between patients. At one facility the nurses didn’t schedule patients for sick call on the facility’s automated scheduling system assuming that it only applied to provider appointments. As a result inmates were brought to sick call only when there was a gap in the provider’s schedule. The numbers of patients seen in sick call each day increased when the nurses started scheduling sick call appointments because waiting time had been eliminated. Collaborating with custody staff may yield other ideas to reduce waiting time especially since sick call competes with other activities they are responsible for overseeing.

Manage time during the clinical encounter: Multi-tasking is a key to managing time during the clinical encounter. Taking the patient’s history and description of the subjective complaint while collecting objective data (taking vital signs, inspecting the area, palpating etc.) is one example. Another is to have the equipment and supplies needed for sick call with you. Stopping the interaction to go across the hall to get a dressing or over the counter medication are time wasters. It is really a waste of time to see patients in a non-clinical setting (cell side or on a tier) since another appointment will be necessary if privacy is compromised, an unclothed exam is needed or a treatment must be given. In other words, handle each request once; don’t generate more encounters because the assessment is incomplete.

Manage the patient: Nurses complain that inmates put in multiple sick call requests, often involving the same problem. The reality is that the primary means to access health care is via sick call. Some systems have looked at the kinds of things that inmates are requesting and considered whether they could be handled through another avenue. Examples of other avenues that have been developed include making over the counter medications more readily available (in the housing unit or on canteen), automatic refills of prescription medication, appointment request forms for the optometrist, mailing lab and radiology results back to the patient, and the list goes on and on. Limiting patients to one request per sick call visit only generates more requests; it is more efficient to address multiple complaints at one encounter. An effective way to manage “frequent flyers” is to schedule appointments with some regularity so that they don’t have to rely solely on sick call requests.

Manage complexity: Several of the experts emphasized the importance of triage in sorting out patients with complex needs and making these the first to be seen. Seeing complex patients early in the day means that there is more time get referrals or additional clinical work accomplished so that their needs are addressed proactively. Explaining this approach of triaging and seeing the complex patients first can also enlist custody staff assistance as necessary. Another approach is to consider group appointments for common problems. I have seen this used at a work camp during a round of winter colds and flu when a quick assessment, patient education and supportive treatment were perfectly appropriate to use in a group setting as long as patients were given the option of a more private encounter.

Contingency planning: No day is ever the same as the next. The number of sick call requests received each day varies and sometimes there will be events that cause the number of requests to skyrocket (e.g. after a disturbance, norovirus or other outbreak, new provider or nurse). A suggested practice is to check in at the half way point; if the number of patients needing to be seen is going to exceed the time available then a backup plan needs to go into effect immediately to prevent backlog. This may mean reassigning staff or re-deploying staff (and mangers and providers) to ensure that all patients are seen timely. Sick call is not a task that gets marked off a list but is instead a dynamic and complex human process that requires attention and commitment to satisfactory completion every day.

 

How does the consensus of an average of seven patients an hour sit with your experience? What advice do you have for nurses who want sick call to become more efficient? Please share your opinion and advice by responding in the comments section of this post. There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Be safe this holiday season!

Photo credit: © Jan Jansen- Fotolia.com

Considering productivity in sick call

mature female nurseNurses at a medium security male facility have asked you to help them get a handle on nurse sick call. They don’t know what is wrong but are burdened by the number of sick call requests that they get every day. There are times during the week when inmates are not seen within the facility’s definition of timeliness. The average number written requests for health care attention that the nurses receive each day is 42. Approximately half of these involve physical symptoms that require a nursing assessment no later than the next day. The nurses see on average 26 patients each day; but only half of these are nursing assessments scheduled from triage of the written request. The other half are urgent walk-ins. There is a backlog of 30 patients who have yet to be assessed by a nurse.

What do the numbers tell: What is your first impression about how nurse sick call is being handled? Looking at the average statistics a backlog can be predicted. If an average of 21 patients each day have concerns that involve physical symptoms then the nurses will need to see that many patients every day to keep up. In this example the nurses are only seeing about 13 patients scheduled from triage of the written request each day so every day eight patients are added to the backlog. To catch up the nurses need to see more than 21 patients a day until the backlog is eliminated.

Underlying principles of sick call: Nursing sick call is considered one of the signature practices defining the specialty of correctional nursing. There are two legal principles underlying nursing sick call. The first is that inmates have daily, unimpeded access to health care. The second is that inmates are entitled to a professional clinical judgment regarding their health concerns. Simply put, inmates can request health care attention every day and their concerns must be addressed in a responsive, timely and clinically appropriate manner (Smith 2013). The failure to see patients, as in the example above, is a violation of these underlying legal principles and puts patients at risk of harm.

What gets measured gets done: Sometimes the never ending onslaught of requests for health care attention can overwhelm nursing staff and becomes a morale and staff retention issue in addition to a legal or risk management problem. Having performance benchmarks for nursing sick call can be helpful in identifying when practices deviate from the norm, considering root causes and developing solutions to improve performance. Based upon your experience how many patients can a proficient nurse see in sick call in an hour? What advice would you give to a nurse who wanted to become more efficient at sick call? Please share your opinion and advice by responding in the comments section of this post.

Next week’s post will include the consensus from nursing colleagues about how many patients nurses can see in an hour of sick call as well as their advice about how to manage sick call efficiently.

There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo credit: © Zdenka Darula- Fotolia.com

Pustules, Furuncles and Petechia, Oh My!

human skin anatomy cross sectionI just spent a week at a correctional facility and while there was privileged to observe several nurses conducting sick call. I came away from these experiences appreciating that this process has become one of the signature practices of the correctional nursing specialty. Sue Smith referred to sick call when done well as “a thing of beauty” in her chapter on the subject in the Essential of Correctional Nursing (page 304). Reflecting on the experience of being with these sick call nurses over the week it occurred to me just how many patients were seen because of skin problems. Complaints included toenail fungus, dry skin, contact dermatitis and acne. Sound familiar? Most nursing protocols for problems related to the skin almost presume a diagnosis first. Here are some examples of these types of protocols: ectoparasite infestation, urticaria, dermatitis, candidiasis infection, bacterial infection, fungal infection, boils, jock itch, warts etc. In order to select the correct protocol the nurse should perform a more general skin assessment first. A thorough assessment and objective description of the condition also should accompany any referral to a primary care provider for more definitive diagnosis and treatment of those conditions not covered by a nursing protocol or that do not respond to nursing intervention.

Subjective description: The following subjects should be covered while gathering information from the patient about a skin problem.

  •      Duration: Is the onset sudden or gradual? Previous episodes or is this the first? Has the condition been persistent or does it fluctuate over time?
  •      Location: Where is it located? Where did it start? Has it spread and if so where?
  •      Provoking or relieving factors: What brought it on, makes it worse and makes it better?
  •      Associated symptoms: Itching, tenderness, bleeding, discharge, generalized or systemic symptoms of fever, pain, malaise?
  •      Response to treatment: What treatment has the patient tried and what was the result? Be sure to include consideration of prescription, over the counter and complementary (herbal, etc.) interventions.

The patient’s medical history and family history may be relevant (chronic or immunosuppressive disease, skin cancer etc.). Other areas to consider in gathering the patient’s subjective data include environmental exposures (work, leisure activity etc.); alcohol, drug and tobacco use, allergies and recent travel. Equipment for a dermatological exam: In terms of the tools of the trade, dermatologists recommend having a magnifying glass and measuring device available. Another recommendation is to ensure adequate lighting. Natural light is best; a hard thing to come by in some correctional facilities. If relying on artificial light, a high intensity, incandescent light is best. In addition a handheld light is helpful to provide lighting from the side when assessing a lesion. Finally, you have to have sufficient privacy for the examination and since the assessment will involve palpation, the hands need to be clean and for the patient’s sake warm. It is always best to tell the patient that you are going to touch them, where and why before you do. This is especially true for patients who have a history of having been traumatized or abused. Examination: The first step is to just look at the patient; do they seem well or ill? Is there any evidence of systemic illness (vital signs, flushing, jaundice, etc.). The next steps are to visually inspect and then palpate the lesion or effected area. Inspection includes the noting the following characteristics:

  • Location – is the lesion or effected area related to sexual contact, exposure to sun or other environmental conditions (chemicals etc.); is it in an area of friction or pressure from clothing, does it involve mucous membranes or areas of perspiration.
  • Number and Distribution – How many? How are they arranged?
Terminology Description
Annular Circular pattern
Confluent Merged or run together
Discrete Separated and distinct from each other
Generalized Scattered over an area
Grouped Clustered in multiples
Linear Line or snakelike shape
Polycyclic Concentric circles like a bull’s eye
Zosteriform Along a nerve root
  •  Characteristics – Size (measure the longest side first). Describe the color and any variation in coloring, including any areas of inflammation. Note whether edges are clearly defined and if the shape is regular or irregular.

Next palpate the affected area for tenderness and warmth. Palpate the lesion to determine where it is located within the three layers of skin (epidermis, dermis, subcutaneous tissue), how thick the lesion is and its consistency (hard, soft, firm, fluctuant). When pressure is applied does the color change or does it break down or bleed easily. Examine regional lymph nodes for tenderness or inflammation. The purpose of inspection and palpation is to obtain an accurate and objective description of the skin problem. There is a vast vocabulary of terms to describe skin conditions. A few of the most common are listed here. A great glossary of dermatological terms can be found at the American Academy of Dermatology.

Type of lesion Description
Atrophic Thin, wrinkled skin
Crust, scab Dried serum, blood or pus
Excoriation Hollowed out or linear area covered by a crust. Caused by scratching, rubbing or picking.
Lichenification Skin thickening
Macule, patch Flat, circumscribed, discolored spot. Macule less than 1 cm (ex. freckle). Patch is larger than 1 cm.
Nodule, papule Solid, palpable lesion. Nodule if greater than 1 cm, papule smaller than 1 cm in diameter.
Petechia, ecchymosis, purpura Extravasation of blood into skin. Petechia are less than 2 mm, ecchymosis larger than 2 mm. Pupura are confluent lesions.
Plaque Well defined plateau above the surface of the skin. As seen in psoriasis or eczema.
Pustule Superficial, elevated lesion containing pus.
Scales Dead skin that flakes or is built up
Scar Fibrous tissue formed after a skin injury
Vesicle, bulla or blister Circumscribed, bump containing clear fluid. Vesicle less than 5mm. Bulla or blister larger than 5 mm.
Wheal Transient, irregular, elevated, indurated, changeable lesion caused by local edema.

Documentation: Once you have taken the patient’s history, collected subjective information about the chief complaint and examined the patient review your documentation of findings to ensure that it is complete. A good description of the lesion will be important in comparing whether the patient’s condition is improving or getting worse with recommended treatment. A focused assessment of a skin condition assists in clinical decisions about which nursing protocol to use and/or the urgency of a provider referral. The key parts of an assessment include:

  • Presenting symptoms
  • History of the complaint
  • Examination
    • Location and size
    • Number and distribution
    • Characteristics of the lesion
  • Documentation of findings

For more about nursing assessment and sick call in the correctional setting go to our book, Essentials for Correctional Nursing. It is the only text published about the unique experience of correctional nursing practice. Order your copy directly from the publisher. Use promotional code AF1209 to receive a $15 discount and free shipping.  By the way, the title of this post, Pustules, Furuncles and Petechia, Oh My! is a riff on the Wizard of Oz, a holiday favorite of mine. Here is a clip from the movie. Enjoy!

References and Resources:

  1. Adult Decision Support Tools: Integumentary Assessment (2014). Remote Nursing Certified Practice. CRNBC Publication 743 at https://www.crnbc.ca/Standards/CertifiedPractice/Documents/RemotePractice/743IntegumentaryAssessmentAdultDST.pdf
  2. American Academy of Dermatology at https://www.aad.org/education/basic-dermatology-curriculum
  3. Hess, C.T. (2008) Practice points: Performing a skin assessment. Advances in Skin & Wound Care: The Journal for Prevention and Healing 21(8): 392-394.
  4. Jail Medicine by Jeffrey Keller at http://www.jailmedicine.com/. Select dermatology from the categories section for several blog posts on dermatology issues in the correctional setting.
  5. Johannsen, L.L. (2005) Skin Assessment. Dermatology Nursing 17 (2): 165-166.
  6. Pullen, R.L. (2007) Assessing Skin Lesions. Nursing 2007 (8): 44-45
  7. Tidy, C. (2014) Dermatological History and Examination. PatientPlus at https://www.patient.co.uk/print/2041

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