describe changes to an individuals's skin condition that should be reported
Skin should be observed in good lighting and any areas of discoloration or redness should be palpated for change in temperature compared to surrounding skin, or feeling of bogginess (soft) or induration (hard). [ Pay particular attention to areas over bony prominences. Blanching erythema is an early indicator of the need to redistribute pressure, non-blanching erythema is suggestive that tissue
damage has already occurred or
is imminent, and indurated or boggy skin is a sign that deep tissue damage has likely occurred.
Ask the patient about:
• areas with lack of sensation;
• areas of pain;
• location of current or previous ulcers;
• fragile skin, easy bruising; and
• medications or medical condition putting at higher risk for breakdown.
Re-inspect and palpate skin of all patients every 8-24 hours, depending on status of patient. Patients at high
risk of breakdown, as determined by either Braden Scale score, may need to be assessed every eight hours
or more frequently as condition changes.
The head-to-toe inspection can be performed at the same time as other assessments. Start at the top and
work downward. A full body skin inspection doesn't have to be visualizing all aspects of the patient in the
same time period.
• When applying oxygen, check the ears for pressure areas from the tubing.
• If on bedrest, don't forget to look at the back of the head during repositioning. ............ ]
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