NCLEX-PN

imbalances, and body build, as well as bone prominence size. Extrinsic factors include environmental humidity, chemical irritants, extreme temperature variations, radiation exposure, and mechanical forces such as pressure, shearing, and friction. Various nursing diagnoses related to skin and skin integrity encompass: ●​ Risk for impaired skin integrity due to immobility

●​ Risk for impaired skin integrity linked to poor skin turgor ●​ Impaired skin integrity due to compromised tissue perfusion ●​ Risk for impaired skin integrity related to bony prominences ●​ Impaired skin integrity due to pressure, shearing, and friction ●​ Impaired skin integrity resulting from inadequate nutritional status

Skin areas exhibiting deviations from normal characteristics indicative of potential breakdown warrant evaluation and description based on color, size, location, odor, drainage, margins, texture, distribution, and underlying bed tissue. Assessment Parameters ●​ Color : Description encompasses shades like yellow, ecchymosed, purple, green, blanched, and reddened. ●​ Size : Measurement in centimeters using disposable rulers for area and depth, enabling calculation of wound dimensions. ●​ Location : Precise anatomical location description, with graphical representation if applicable. ●​ Odor : Description of odors (malodorous, pungent, foul, musty) and association with pathogens ●​ Drainage or Exudate : Amount, color, and characteristics, categorized as serous, sanguineous, serosanguinous, or purulent. ●​ Texture : Assessment of affected skin areas as macerated, edematous, swollen, indurated, or normal. ●​ Distribution : Characterization as generalized, localized, asymmetrical, or symmetrical ●​ Margins: Description of color, characteristics, and texture, distinguishing open, attached, unattached, well-defined, and healing ridge margins. ●​ Underlying Bed Tissue : Reflection of wound healing stages—homeostasis, inflammation, proliferative/granulation, maturation—assessing tissue renewal progress

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