Prepared and Presented by: Ms. Sohad Noorsaeed, RN. MSN

Transcription

1 Prepared and Presented by: Ms. Sohad Noorsaeed, RN. MSN

2 Learning Outcomes Upon the completion of Skin integrity lecture, the learners will be able to: 1. Describe factors affecting skin integrity. 2. Identify clients at risk for pressure ulcers. 3. Describe the four stages of pressure ulcer development. 4. Identify assessment data pertinent to skin integrity, and pressure sites. 5. Discuss measures to prevent pressure ulcer formation. 6. Describe nursing strategies to treat pressure ulcers.

3 Introduction The skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury. It provides mechanical and immunological protection, thermoregulation, neurosensorial function, vitamin D synthesis, and homeostasis of fluids, electrolytes, and proteins.

4 SKIN INTEGRITY Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds. factors affecting skin integrity: Internal Genetics (skin color, allergies, sense to light). Age. Health status ( clients with impaired peripheral arterial circulation may have skin on the legs that appears shiny, has lost its hair, and damages easily External Activity, diet

5 TYPES OF WOUNDS

6 Incision

7 Contusion

8 Abrasion

9 Puncture

10 Laceration

11 PRESSURE ULCERS Pressure ulcers (also called bed sores, pressure sores, or decubitus ulcers). a pressure ulcer is defined as a localized injury to the skin and/or underlying tissues usually over bony prominences, as a result of pressure, or pressure in combination with shear (cut).

12 Etiology of pressure ulcers Pressure ulcers are due to localized ischemia, a deficiency in the blood supply to the tissue. The tissue is compressed between two surfaces, usually the surface of the bed and the bony skeleton, with greater than 32 mmhg pressure. When blood cannot reach the tissue, the cells are deprived of oxygen and nutrients and the tissue consequently dies. After the skin has been compressed, it appears pale, as if the blood has been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush, called reactive hyperemia due to vasodilation. If the redness disappears in that time, no tissue damage can be anticipated. If, however, the redness does not disappear, then tissue damage has occurred.

13 Risk factors of pressure ulcers Immobility and inactivity. Inadequate nutrition. Fecal and urinary incontinence. Decreased mental status. Diminished sensation. Excessive body heat. Advanced age. Presence of certain chronic conditions. Friction (a force acting parallel to the skin surface by sheets rubbing against skin) shearing force (a combination of friction and pressure) are other factors frequently acting in conjunction with pressure to produce pressure ulcers.

14 Stages of Pressure Ulcers

15 Stage I

16 Stage II

17 Stage III

18 Stage IV

19 Risk Assessment Tool Risk assessment tools (also called risk assessment scales, calcu-lators, or scores) are key components in any prevention guidelines and constitute an initial step in pressure ulcer prevention models that aim to identify those patients at risk. Risk assessment tools are structured models including categories of factors that are associatedto varying degrees of reliability, with pressure ulcer development. There are several published risk assessment tools such as the Norton scale, Waterloo scale, and Braden scale.

20 Braden Scale In the Braden scale six risk factors (or risk indicators) are considered: sensory perception, moisture, activity, mobility, nutritional status, and shear/friction. Each category is rated 1 to 4 except shear/friction, which is rated 1 to 3. The minimum risk score is 6 and the maximum is 23. Patients are deemed to be at risk when their cutoff score is 18.

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22 NURSING MANAGEMENT Assessing: When a pressure ulcer is present, the nurse notes the following: Location of the ulcer, related to a bony prominence. Size of ulcer in centimeters. Presence of undermining or sinus tracts, assessed as a clock face, with 12 o clock as the client s head. Stage of the ulcer. Color of the wound bed and location of necrosis (dead tissue) or eschar. Condition of the wound margins. Integrity of the surrounding skin. Clinical signs of infection, such as redness, warmth, swelling, pain, odor, and exudate (note color of exudate).

23 Diagnosing The NANDA nursing diagnoses (2007) that relate to clients who have skin wounds or who are at risk for skin breakdown are Risk for Impaired Skin Integrity: At risk for skin being adversely altered Impaired Skin Integrity: Altered epidermis and/or dermis Impaired Tissue Integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.

24 Additional nursing diagnoses may be appropriate for clients with existing impaired skin or tissue integrity. Examples of these diagnoses include: Risk for Infection if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma Pain related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound.

25 Nursing Intervention Preventing and Treating Pressure Ulcers To reduce the likihood of pressure ulcer development in all clients, the nurse employs a variety of preventative measures to maintain skin integrity. 1- MAINTAINING SKIN HYGIENE. 2- AVOIDING SKIN TRAUMA.

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