If lesions are present, describe Pressure ulcer: them in as much detail as Stage 1: Intact skin with possible in relation to color, redness of a localized type, and distribution area usually over a bony If a pressure is present, prominence. Darkly pigmented describe exact location, size skin may not have a visible (measure diameter and depth), blanching; in dark skin tones only stage, and drainage. A it may appear with persistent blue photograph of the ulcer may be or purple hues. useful as a means to accurately Stage 2: Partial thickness loss of record the status of the ulcer dermis presenting as a shallow and evaluate progress. Stage open ulcer with a red or pink pressure ulcers based on the wound bed, without slough. May following criteria: also present as an intact or open/ruptured blister. Full thickness tissue loss. Stage 3: Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable ulcers are assessed separately as: Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Unstageable - Deep tissue: Suspected deep tissue injury in process. Reverse staging is not appropriate. MENTAL STATUS Note general appearance, Inappropriate dress or behaviors, appropriateness of dress, body associated with delirium, language, general behavior, dementia, depression. language, speech, affect, and responses to questions. Ask if resident sad, unusually Extreme sadness, associated with nervous, suspicious of others; depression. sees or hears things that others
If lesions are present, describe them in as much detail as possible in relation to color, type, and distribution If a pressure is present, describe exact location, size (measure diameter and depth), stage, and drainage. A photograph of the ulcer may be useful as a means to accurately record the status of the ulcer and evaluate progress. Stage pressure ulcers based on the following criteria: Pressure ulcer: Stage 1: Intact skin with redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable ulcers are assessed separately as: Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Unstageable - Deep tissue: Suspected deep tissue injury in process. Reverse staging is not appropriate. MENTAL STATUS Note general appearance, appropriateness of dress, body language, general behavior, language, speech, affect, and responses to questions. Ask if resident sad, unusually nervous, suspicious of others; sees or hears things that others Inappropriate dress or behaviors, associated with delirium, dementia, depression. Extreme sadness, associated with depression.
Interpreting%20Nursing%20Assessment%20Findings.docx