Integumentary Skin

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Trace DC12-2

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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1. Purpose and clinical relevance

Skin is the body's largest organ and its first barrier, and in an immobile, incontinent, poorly nourished, or vascularly compromised patient it can break down quickly and predictably. The skilled value is identifying who is at risk before injury occurs — a Braden score, a non-blanchable area over the sacrum, moisture-associated damage — and instituting prevention, because a pressure injury is far easier to prevent than to heal. That risk assessment and prevention require nursing judgment.

The purpose of this module is to give clinicians the skilled framework and chartable language that demonstrate skin assessment, pressure-injury risk scoring, and prevention were reasonable and necessary and required the skills of a licensed nurse. It is the primary home for skin assessment and pressure-injury risk; the staging and treatment of existing wounds and pressure injuries are cross-linked, not duplicated, into the Wounds / Pressure Injury reference.

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