When you are assessing an individual’s skin you must look for at the locations on an individual’s skin which are most likely to be prone to skin breakdown such as the back of the head, sacrum, heels, spine, elbows and anywhere else on an individual’s body that has a bony prominence. You must always state the location of the pressure ulcer in the correct paperwork such as daily notes, body map etc. stating the staging of the ulcer, including the depth, width and length in centimetres. You should also note the presence of undermining, tunnelling, sinus tracts and any exudate (if present, the colour and amount). You should also look at the wound bed checking the appearance and the type of tissue visible (layers of skin, muscle, bone and any necrotic tissue) and the wound edges looking carefully for evidence of induration(hardness), maceration(moisture), rolling edges and any redness. You should also take into account the presence or absence of pain and the presence or absence of odour as these can be indicators of the severity of the pressure ulcer.
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