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Skin: Integumentary
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Assess
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Document: Assessment, Interventions,
Outcomes
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Color
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Cyanosis, redness, pallor, or jaundice.
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Temp
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Coolness or warmth.
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Moisture
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Diaphoresis or excessive dryness.
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Turgor
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The time it takes the skin to flatten out after pinching section
over forehead or sternum (do not use hand or arm; these are unreliable
areas); poor skin turgor may indicate dehydration (may be normal in elderly).
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Edema
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Extremities, sacrum, dependent side (if debilitated, bedfast, or
chairfast), facial/sclera, bilateral vs. unilateral.
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Lesions
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Presence and type of skin lesions.
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7/7/14
Skin: Integumentary
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