![]() Positioning of tubes and drains can be a source of impaired tissue integrity if not monitored appropriately. #Impaired skin integrity skinIncontinence, wound drainage, and perspiration can be potential factors for skin breakdown. Note whether the patient is incontinent or if there are areas of the body constantly exposed to moisture. Mobility limitations pose a risk factor for developing tissue damage. Therefore, pain control is an integral part of the treatment plan.Īssess the patient’s mobility status and range of motion. These values indicate signs of infection and malnutrition, which can cause tissue breakdown and complications with healing. Monitor WBCs, prealbumin, albumin, and total protein levels. Monitor for an elevated body temperature.įever may be a sign of a systemic infection. In addition, noticing breakdown early in this area allows for pivot and implementation of other strategies to dress the wound. It is essential to assess this area regularly because dressings are often secured at this area. As the wound heals, drainage should decrease. Serosanguinous drainage may be expected, while purulent drainage or pus may be signs of infection. Color and amount of drainage provide information about appropriate wound healing processes. Note the amount of drainage present and the number of dressing changes necessary to keep the area dry. Wound odor can come with exudate and may be a sign of infection. – Area is entirely covered with slough and eschar, so the stage cannot be determined – Palpable bone, muscle, and tendon tissue – Ulcer may be characterized as an abrasion or blister (open or fluid-filled) – Skin is intact but red and non-blanchable – Affected area may have felt firm, boggy, mushy, warmer, or cooler to touch – Blood filled tissue due to underlying tissue damage ![]() – Skin is intact appears purple or maroon Key features of pressure ulcers Suspected Deep tissue injury: Use the staging criteria recommended by the National Pressure Ulcer Advisory Panel. ![]() A nurse that is specialized in wound care should be consulted to assist with appropriate wound staging. For example, if the wound is located over a bony prominence, it may be a pressure injury. Use terms such as proximal, distal, anterior, medial, and posterior to clarify wound locations. It may be helpful to use a visual aid such as a body diagram to mark all wounds and incisions. Determine the size, depth, and other characteristics. This process is necessary so that appropriate interventions can be implemented.Īssess the affected area of tissue damage. Tissue can be compromised by acute or chronic health conditions, physical limitations, or equipment. The etiology of compromised tissue can vary widely. Understanding the patient profile helps determine the right treatment plan. With surgery incisions, this patient may have a greater risk for compromised skin integrity. Another example may be a patient recovering from recent surgery. For example, diabetes mellitus can cause complications with wound healing because high blood sugars cause a delay in wound healing. Past medical history and the patient’s current clinical status often reveal conditions that explain the patient’s susceptibility to compromised tissue integrity. Consider comorbidities such as diabetes, peripheral artery disease, past procedures, and nutritional status. Pay special attention to bony prominences that are at high risk for tissue injury.Ī complete head-to-toe audit provides the nurse with a baseline condition of the skin that can be used for comparison when skin damage is noted. Perform a complete body audit on admission and at designated times. ![]()
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