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Assess of Skin Integumentary

Staging Pressure Sores


Assess
Document: assessment, interventions, outcomes
Color
Cyanosis, redness, pallor, or jaundice.
Temp
Coolness or warmth.
Moisture
Diaphoresis or excessive dryness.
Turgor
The time it takes the skin to flatten out after pinching
a section on top of hand poor skin turgor may
indicate dehydration; called tenting.
Edema
Extremities, sacrum, dependent side (if debilitated, bed-,
or chairfast), facial/sclera, bilateral versus unilateral.
Lesions
Presence and type of skin lesions.

Staging Pressure Sores

Stage I
Intact, nonblanching erythemic area. Indicates potential
for ulceration.
Stage II
Interruption of epidermis, dermis, or both; presents as
an abrasion, blister, or very shallow crater.
Stage III
Full-thickness crater involving damage and/or necrosis
down to, but not penetrating, the fascia.
Stage IV
Full thickness, similar to stage III, but penetrating the
fascia with involvement of muscle, bone, and
supporting structures. May involve undermining.
Note:
Ulcers that are covered with eschar cannot be staged
without debridement.

Risk Factors for Developing Pressure Sores
Alterations in sensation or response to discomfort: Degenerative neurological/neuromuscular disease, cerebrovascular disease, brain or spinal cord injury, depression, or drugs that adversely affect alertness.
Alterations in mobility: Neurological disease/injury, fractures, contractures, pain, or restraints.
Significant changes in weight: Protein-energy malnutrition (PEM), severe edema, obesity.
Medical conditions: Malnutrition and dehydration, diabetes mellitus, peripheral vascular disease, end-stage renal disease, congestive heart failure, malignancies, chronic obstructive pulmonary disease, obesity, or bowel and bladder incontinence.
Skin Integumentary
Areas Susceptible to Pressure Sores

Supine:
1. Occipital area
2. Scapula
3. Elbows
4. Sacrum
5. Ischium
6. Heels

Side-Lying:
7. Ears
8. Shoulders
9. Trochanter
10. Knees
11. Ankles

Prone:
12. Iliac crests
13. Knees
14. Toes

Sitting:
15. Scapula
16. Sacrum
17. Ischium
18. Rear knees
19. Sole of foot


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