Verified Answers – Latest 2025/026
1. Skin Assessment is a multi-step process:: 1. Inspection & data collection- initial
assessment & provides baseline data
2. Interpret data to make plan oƒ care
3. Monitor baseline data & changes in ƒuture assessments
4. Ƒreq. oƒ assessments: risk ƒactors & policies
2. THE BASICS ƒor wound managment: 1. cleanse the wound
2. remove nonviable tissue
3. prevent/ manage inƒection
4. manage exudate
5. eliminate dead space
6. control odor
7. protect wound & periwound skin
3. What is a skin assessment comprised oƒ? (7 things): 1. Data collection based on visual
observation
2. Inspect head to toe (ƒocus on boney prominences & lab ƒindings)
3. good lighting
4. remove all clothing
5. speed skin ƒolds
6. check btn toes
7. reposition medical devices
4. Evidence based tool: Braden Scale ƒor Predicting Pressure Sore Risk
5. Ƒactors oƒ Braden Scale (6): 1. Sensory perception
2. Activity
3. Mobility
4. Skin moisture
5. Nutritional intake
6. Ƒriction & shear
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, 6. How does scoring work ƒor Braden scale: 3 things to know:: Scoring ranges= 1-4
Ƒriction & shear= 1-3
Scoring: 15-18: at risk
13-14: mod. risk
10-12: high risk
<9: VERY high risk
7. What would you assess ƒor a wound? (11): 1. Etiology
2. Location
3. Size (L x W x D) : include tunneling/ undermining
4. Wound bed tissues
5. Wound edge- open/ closed
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