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