Intensive care patients with wounds require additional documentation to tell why they may be predisposed to skin failure.
Pre-albumin, albumin, transferrin levels
Use of vasoconstrictive agents
Mention if the patient is “too unstable to turn” or has to be “turned less often”
Days in bed and days without nutrition
Discuss low body mass index on admission
Discuss and document that you have discussed skin failure with the patient, family, and caregivers.
Skin Failure is “An event where skin and underlying tissues die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems.”
Langemo D, Brown G Skin Fails Too, Acute, Chronic, and End-Stage Skin Failure. Advances in Skin Wound Care. 2006 May;19(4):206-212.
Matthew Livingston R.N. C.W.S.