Skin survelance
inspect skin and mukose for redness, extreme, warmth, edema, or
drainage
observe extremitas for color, warmth, swelling, pulse, texture,
edema, and ulceration
use an assessment tool to identify patients at risk for skin
breakdown (braden scale)
monitor skin color and temperature
monitor skin for rashes and abrasion
monitor skin for excessive dryness and moistness
monitor for sources of pressure and friction
inspect clothing for tightness
institute measures to prevent further deterioration (overlay
mattress, repositioning schedule)
instruct family member / care giver about signs of skin breakdown,
as appropriate