See Table 10.6b for components to include in a wound assessment. If a wound is present, it is assessed during every dressing change for signs of healing. Routine skin assessment should continue throughout a patient’s stay, usually on a daily or shift-by-shift basis based on the patient’s condition. Agencies are not reimbursed for care of pressure injuries received during a patient’s stay, so existing wounds on admission must be well-documented. When performing an objective integumentary assessment on a patient receiving inpatient care, it is important to perform a thorough exam on admission to check for existing wounds, as well as to evaluate their risk of skin breakdown using the Braden Scale. Have you had any changes in eating habits, feelings of depression or social isolation, or a reduction in your usual activity levels? Has this wound impacted your quality of life? How many cigarettes do you smoke a day? How long have you smoked? Have you considered quitting smoking? How do you cope with stress in your life? Have you experienced any recent stressors such as surgery, hospitalization, or a change in life circumstances? Symptoms of Infection (pain, purulent drainage, etc.)Īre you experiencing any symptoms of infection related to this wound such as increased pain or yellow/green drainage? What have you used to try to treat this wound? If chronic wounds or wounds with delayed healing are present:Īre you taking any medications that can affect wound healing, such as oral steroids to treat inflammation or help you breathe? Have you ever been diagnosed with a wound related to diabetes, heart disease, or peripheral vascular disease? Read more about the PQRSTU method in the “ Pain Assessment Methods” section of the “Comfort” chapter. Use the PQRSTU method to comprehensively assess pain. Do you have any symptoms of infection in the wound, such as increased redness, drainage, warmth, or tenderness around the wound?.Table 10.6a Interview Questions Related to Integumentary DisordersĪre you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole?ĭo you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury? These changes include altered eating habits, depression, social isolation, and a gradual reduction in activity levels. The loss of independence associated with functional decline can also lead to changes in overall health and well-being. Reasons for this include the frequency and regularity of dressing changes, which affect daily routine a feeling of continued fatigue due to lack of sleep restricted mobility pain odor and the side effects of multiple medications. Several studies have shown that patients with nonhealing wounds have a decreased quality of life. If a patient has a chronic wound or is experiencing delayed wound healing, it is important for the nurse to assess the impact of the wound on their quality of life. See Table 10.6a for a list of suggested interview questions to use when assessing a patient with a wound. For patients with chronic wounds, it is also important to identify factors that delay wound healing, such as nutrition, decreased oxygenation, infection, stress, diabetes, obesity, medications, alcohol use, and smoking. If a patient has a wound, it is important to determine if a patient has pain associated with the wound so that pain management can be implemented. Open Resources for Nursing (Open RN) Assessment Subjective Assessmentĭuring a subjective assessment of a patient’s integumentary system, begin by asking about current symptoms such as itching, rashes, or wounds.
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