If lesions are present, describe them in as much detail as possible in relation to color, type, and distribution If a pressure is present, describe exact location, size (measure diameter and depth), stage, and drainage. A photograph of the ulcer may be useful as a means to accurately record the status of the ulcer and evaluate progress. Stage pressure ulcers based on the following criteria: Pressure ulcer: Stage 1: Intact skin with redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable ulcers are assessed separately as: Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Unstageable - Deep tissue: Suspected deep tissue injury in process. Reverse staging is not appropriate. MENTAL STATUS Note general appearance, appropriateness of dress, body language, general behavior, language, speech, affect, and responses to questions. Ask if resident sad, unusually nervous, suspicious of others; sees or hears things that others Inappropriate dress or behaviors, associated with delirium, dementia, depression. Extreme sadness, associated with depression.
don't; or, has thought about suicide. Test cognitive function using tool accepted by facility. Areas of function assessed include: Orientation: This includes the person's knowledge of his/her own name, current location, date, time of day, and season. Language: Spontaneous speech and appropriateness of responses throughout the interview assist in assessing language function. In addition, the person can be asked to name objects that are pointed to or repeat phrases. Memory: At the start of the examination the person is given three unrelated words (e.g., dog, cup, bed) and asked to repeat the words and remember them. Midway through the examination and again at the end, the person is asked to repeat the words. Attention and concentration: The person is asked to spell the word world backwards or to count backward from 100 by 7s. Executive function: The person is asked to state what two words have in common (e.g., apple and banana, shoe and sock, coffee and tea) or to list in a minute as many words as possible starting with the same letter. Ability to follow three-stage command: The person is given instructions to follow three basic acts, such as pick up the piece of paper, fold it in half, and hand it to me. Orientation to person, and time. Appropriate use of language. Ability to recall Ability to spell word world backwards or count backwards from 100 by 7s for 5 times. Ability to identify similarity in Ability to follow three-stage command. Nervousness, associated with anxiety. Suspiciousness, associated with paranoia. Seeing or hearing things others do not, associated with delusions, hallucinations. Suicidal thoughts. Altered cognitive function, associated with delirium or dementia.