Patient was instructed on the importance of skin integrity to prevent future complication: Massage reddened skin gently al least 3 or 4 times daily. Keep the skin clean and dry and after use a protective ointment or spray.
Patient was instructed on factors that contributes to poor skin integrity, such as, immobilization, poor circulation, moisture, heat, anemia, shearing forces poor nutritional status, etc.
Patient was instructed on measures to protect the skin, such as, keeping the skin clean and dry, assessing frequently for skin breakdown, avoiding powder due to possible caking and irritation.
SN instructed patient and caregiver that the key difference between a suspected deep tissue injury (sDTI) and an unstageable pressure ulcer is that sDTI involves intact skin, whereas an unstageable ulcer involves a breakdown into at least the subcutaneous tissue. An unstageable ulcer is covered with necrotic tissue, such as slough or eschar, formed from remnants of the collagen matrix of subcutaneous tissue. So it’s always a full-thickness ulcer either stage III or stage IV.
SN instructed patient and caregiver on preventing skin tears. In terms of prevention, protective arm sleeves are helpful. The use of paper or gentle release tapes is also a better alternative to nylon tape, when it comes to sensitive or aging skin. In addition, it is important to routinely moisturize dry skin with an appropriate moisturize barrier. As we age, hydrating dry skin helps to replenish missing skin and keep skin healthy and intact. Oral hydration is important as well. Patient and caregiver verbalize understanding instructions given.