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Skin surveillance

Collection and analysis of patient data for the purpose of maintaining the integrity of the skin and mucous membranes.


– Maintain skin and membrane integrity. – Prevent wound infections. – Educate patient and family on warning signs and symptoms. – Equipment: – Nursing assessment sheet completion guide.


– Nursing assessment sheet. – Nursing care planning sheet.


– Preserve the patient’s privacy. – Inform the patient. – Ask the patient and family to cooperate. – Inspect the condition of the incision or wound, if applicable. – Observe its color, heat, pulses, texture, if there is swelling, edema and ulcerations in the extremities. – Observe for redness, extreme heat and loss of skin integrity, rashes and abrasions. – Observe for sources of pressure and friction (see figure for pressure zones). – Observe for infections. – Observe for excessive moisture or dryness of the skin. – Watch for skin color. – Check skin temperature. – Institute appropriate measures to prevent further deterioration. – Instruct patient and family on signs of loss of skin integrity. – Record in nursing documentation: skin assessment, date and time, incidents and patient response.

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