- Based on your patient's condition, assesses a minimum of two vulnerable skin surfaces for the list:
- heels
- sacral/coccyx
- occiput
- trochanters
- skinfolds
- peri anal
- designated area(s)
- for -
- color changes
- integrity (e.g. lesions, ras, shear and pressure effects, skin tears)
- temperature
- edema
- moisture (e.g. perspiration, incontinence, diarrhea, non intact ostomy/drainage system)
- Records assessment data of two vulnerable skin surfaces including any designated area(s) related to:
- color changes
- integrity (e.g. lesions, ras, shear and pressure effects, skin tears)
- temperature
- edema
- moisture (e.g. perspiration, incontinence, diarrhea, non intact ostomy/drainage system)
Mneumonic -
TIME to check Color of skin
Temperature
Integrity
Moisture
Edema
Color
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