 |
|
|
 |
|
|
|
The following provides a guideline for clinical assessment. Assessments must be done at regular intervals and are used to drive treatment decisions.
- Assessment of risk or contributing factors associated with skin breakdown should be determined from the patient’s history. A summary of risk factors and types of impaired skin integrity follows:
|
|
| Problem |
Local Risk Factors |
Systemic Risk Factors |
| Stripping/Shearing Injury |
Mechanical
TraumaI
Ischemia
Dry Tissue |
Elderly
Immobility
Malnutrition |
| Perineal Skin Compromise |
Incontinence
Inadequate hygiene
Mechanical trauma |
Recent antibiotic use
Elderly
Malnutrition |
| Arterial Ulcer |
Mechanical trauma |
Peripheral vascular disease
Smoking
Elderly |
| Neuropathic Ulcer |
Mechanical trauma |
Diabetes
Spinal cord injury |
| Pressure Ulcer |
Moisture
Mechanical trauma
Malnutrition |
Immobility
Decreased activity
Sensory perception deficits |
| Venous Ulcer |
Oedema
Cellulitis
Mechanical trauma |
History of deep vein thrombosis
Previous leg ulceration
Obesity |
|
|
- General assessments: include patient’s current health status, disease processes, age, activity level, nutrition, and medications.
- Assessment of the skin: colour, temperature, sensation (e.g., pain, itching), hydration (e.g., dry, cracked, moist), tissue consistency (e.g., firm, boggy), thin skin, presence of oedema, induration, changes in any of the above, and presence of healed ulcer or incision.
- Assessment of nutrition, hydration, current skin care, patient/caregiver level of understanding, compliance in care, and learning style.
|
|
| < back |
|
|
|
