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Regular wound marginsCallus around wound
Skin temp: warmer or coolerTissue consistency: firm or softTissue sensation: Pain
q 3-5 days and prn
Dermal wound cleaner
Skin tearsTape burnsPerineal dermatitismacerationExcoriation
Metatarsal headsTops of toesHeels
Brown discolorationedemaDry, scaly skin
Cleanse and dry area, cover with non-adherent dressing; for mod to
heavy drainage, use alginate or non-adhesive foam for absorption to
prevent maceration; secure dressing with gauze wrap or netting
Minimal exudatepale wound bedwell defined margins
Lower calf and ankle in area covered by a sock
"interdry"; silver impregnated cloth to be put in between fat folds
Decreased sensation (neuropathy)Warm skin
Zinc oxide, used in lactulose therapy, for exampleNote: do not attempt to clean off completely after each incontinence episode
Oxygen tubingUrinary catheter drainage tubingCastsEndotracheal/nasogastric tubesTracheostomy tube ties
Assess skin on admission, q shift and prn (4 eyes)Braden scale
admission, q shift and with level of care changeNutrition, optimize or
improveAssess bony prominences, esp heels and sacrumDecrease friction
and shearing
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