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Assess site of impaired tissue integrity and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, strain ulcer, leg ulcer). 2. Decide dimension and depth of wound (e.g., full-thickness wound, stage III or stage IV stress ulcer). 5. Monitor status of skin around wound. Monitor client's skin care practices, noting sort of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.

Individualize plan in response to consumer's skin situation, wants, and preferences. 6. Monitor shopper's continence standing and reduce exposure of skin impairment site and different areas to moisture from incontinence, perspiration, or wound drainage. 7. If consumer is incontinent, implement an incontinence administration plan to stop publicity to chemicals in urine and stool that may strip or erode the skin. 8. Monitor for right placement of tubes, catheters, and different gadgets.

Mechanical harm to skin and tissues because of strain, friction, or shear is often related to exterior devices. 9. In orthopedic purchasers, test every 2 hours for right placement of foot boards, restraints, 모바일카지노 traction, casts, or other devices, and assess skin and tissue integrity.