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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
Friction and shear looks at the amount of assistance a client needs to move and the degree of sliding on beds or chairs that they experience. This category is assessed because the sliding motion can cause shear which means the skin and bone are moving in opposite directions causing breakdown of cell membranes and capillaries. Moisture enhances ...
The shared objective of treatment and prevention is maintenance and/or restoration of the integrity and healthy functionality of skin surrounding the wound. Main treatment and prevention strategies include the following: Holistic wound assessment that includes periwound assessment. [1] Elimination of factors causing moisture-associated skin damage.
A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. [1] The major function of this system is as a barrier against the external environment. [2]
Skin type/visual risk areas; Sex and age; Malnutrition Screening Tool; Continence; Mobility; Additional points in special risk categories are assigned to selected patients. Tissue malnutrition; Neurological deficit; Major surgery or trauma; Potential scores range from 1 to 64. [1] A total Waterlow score ≥10 indicates risk for pressure ulcer ...
Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health.
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Total body surface area (TBSA) is an assessment of injury to or disease of the skin, such as burns or psoriasis. In adults, the Wallace rule of nines can be used to determine the total percentage of area burned for each major section of the body.