Patient was instructed on the importance of skin integrity to avoid future complication. With a good skin care it is possible to prevent most pressure sore (bed sores), that can develop quickly in people who are very thin or obese, or who collect fluids in their tissues, who have poor nutrition, who are elderly.
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 skin care. Look at the body after washing. Make sure there are no dry, red or sore spots that could become infected.
Patient was instructed on skin care. Treat cuts right away. Wash them with soap and water. Avoid antiseptics, iodine or alcohol to clean cuts, because they are too harsh. It is recommended to put antibiotic cream or ointment on minor cuts.
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.