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ABRASION

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PHYSICAL DATA

. Outline of abrasion (dimension, location, etc. )
. Whether or not significant bleeding or pain is present at
the abrasion site
. lf reporting a complication of an existing abrasion,
any signs of infection or significant bleeding
. Description of skin condition around the abrasion
(normal, reddened, enlarged, tender, etc. )

MEDICAL BACKGROUND

. Patient’s age and sex
. Date and circumstance of onset (exactly how abrasion
developed, if known)
. All current medications, including any recent
alterations, especially anticoagulants, prednisone,
and additional prescription medication associated with thin or
fragile skin
. Whether person has background of fragile skin or
frequent skin tears
. Outcomes of any interventions thus far

ABRASION ASSESSMENT
Include the following when describing an abrasion:

Precise location (temple, wrist, forearm, hand, etc. )
. Duration (how long has it been there? )
. Size (width, length, depth) in mm, cm
. Drainage (colouring, scent, volume)
. Does it feel tender?
. ls it warm to touch?
. Is there swelling?
. Is the location reddened?
. Grievances of soreness, tightness, itching, or additional symptoms

Investigate source of abrasion and document
nursing methods to lessen chances of this
happening again. Update the resident’s care plan in ‘Real Time”.

Check on status of previous tetanus shot. Alert practitioner of when last tetanus shot was given or if you can not find status of last tetanus shot.

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