LICENSED VOCATIONAL NURSING PROGRAM
1ST SEMESTER FUNDAMENTALS
CLIENTS WITH SPECIAL NEEDS
CHAPTER 48 - SKIN INTEGRITY
INTRODUCTION
Immobilization can have detrimental effects on a client’s skin integrity. A major aspect of nursing care focuses on the maintenance of skin integrity along with planning interventions that prevent skin breakdown. These planned interventions ensure quality nursing care.
OBJECTIVES
Upon completion of this unit, the student will be able to:
A. Theory
1. Identify the pressure points on the body where pressure sores are most apt to develop.
2. Describe the four stages of pressure sores.
3. Identify the risk factors for developing pressure sores.
4. List the nursing interventions used to prevent or treat pressure sores.
ASSIGNMENT
A. Read Chapter 48- Potter & Perry, pgs. 1278 – 1311 and Critical Thinking Exercises # 2, 4, and Review Questions associated with skin integrity
B. Study Guide for Chapter 48
Chapter 48 Skin Integrity
· Immobilization can have detrimental effects on a client’s skin integrity
· A major aspect of nursing care focuses on the maintenance of skin integrity along with planning interventions that prevent skin breakdown
· These planned interventions ensure quality nursing care
· Statistical Facts
· Patients who develop pressure ulcers
o 10% of all hospitalized patients
o 66% of elderly patients
o 33% critical care patients
o 23% patients in nursing homes
· Sub-population at greater risk
o Quadriplegic
o Elderly
o Orthopedic
· Assessment
· Effect of immobility on the skin is compounded by impaired body metabolism and negative nitrogen balance
· Any break in skin may lead to further complications
· Bedsore = pressure ulcer = decubitus ulcer
· Pressure ulcer is defined as ischemic lesion of the skin and underlying tissue, caused by external pressure that impairs the flow of blood and lymph
· Risk Factors
· External pressure exerted in one of these ways:
o Direct pressure
§ Weight of body against bed, chair, or wheelchair
o Shearing force
§ Pressure exerted against the skin in a direction parallel to the body’s surface
o Friction
§ The mechanical force exerted when skin is dragged across a coarse surface
§ Affects the epidermis
o Pathophysiology
· Direct pressure causes tissue ischemia
· Shearing causes stretching and bending of blood vessels causing thrombosis
· Friction and moisture cause skin and fascia to remain fixed to the bed and deep fascia and skeleton slides in the direction of body movement
· Continuous pressure impedes blood flow causing tissue ischemia and hypoxia
· Cells and tissues die causing necrosis
· Position Pressure Points
· Sitting ischeal tuberosities; sacrum
· Supine back of skull, elbows, sacrum, ischeal tuberosities, heels
· Prone elbows, knees, toes
· Side-lying knees, greater trochanter
· Stages of Decubitus Ulcers
· STAGE I reddened skin; intact
· STAGE II reddened edema that does not
o disappear; epidermis/dermis
· STAGE III sloughing off of necrotic tissue;
o subcutaneous tissue
· STAGE IV full-thickness skin loss;
o extensive destruction
· Staging Limitations
· Stage I identification may be difficult with darkly pigmented skin
· Accurate staging cannot take place with eschar present
· Eschar must be removed for healing to occur
· Research
· Early identification of risk factors is necessary in the prevention of decubitus ulcer formation
· High risk patients include:
o Elderly
o Immobility
o Limited mobility
o Incontinent
o Nutritional deficits
o Chronic disease
o Impaired sensory input
·
· Assessment Scales
· Norton Scale
o 5 risk factors:
§ Physical condition, mental condition, activity, mobility, incontinence
· Braden Scale
o 6 risk factors:
§ Sensory perception, moisture, activity, mobility, nutrition, friction and shear
· Braden Scale is the most commonly used assessment scale
· Interventions
to prevent ulcer formation
· Identify susceptible clients
· Routinely examine skin
· Change position to relieve pressure
· Avoid pressure over bony prominences
· Pressure relieving devices
· Keep skin clean and dry
· Interventions
to treat ulcer formation
· Keep ulcer clean
· Debride necrotic tissue or eschar
· Use skin products to lubricate, stimulate circulation, and promote wound healing
· Stage I –
o provide moisture barrier and remove pressure – skin prep, sween cream, granulex, transparent dressings
· Stage II –
o transparent dressings, hydrocolloid dressings – prevent breakdown, promote healing
· Stage III –
o wet to dry dressings, hydrocolloid dressings
· Stage IV –
o wet to dry dressings, kerlix, dry gauze, transparent and hydrocolloid dressings
· Products used for Stage III and IV
· Restore – pectin based
· Accuzyme Cream – aides in debriedment
· Proteolytic enzymes (Elase) – debriding agents useful with infected wounds
· Interventions
to treat ulcer formation
· Increase protein intake 2 to 4 times normal
o Protein helps rebuild tissue
o Recommended daily requirement is:
§ For men – 70 grams
§ Women – 60 grams
· Increase calories at least 1 ½ times norma
l
o Increased calories rebuilds SQ tissue
· Increase Vitamin C
o Promotes protein synthesis and tissue repair
· Nursing Care
· Identify clients at risk
· Assess clients on admission
o Document
· Daily skin assessment
· Cleanse soiled skin immediately
· Use moisturizers on skin
· Avoid massage over bony prominences
· Proper positioning
· Maintain nutrition
· Maintain activity – use pressure relieving devices
· Nursing Diagnoses
· Anxiety r/t pain and loss of skin from pressure ulcer
· Body image disturbance r/t large pressure ulcer
· High risk for infection r/t sacral pressure ulcer and fecal or urinary incontinence
· Pain r/t pressure ulcer
· Impaired skin integrity r/t immobility, chronic disease, incontinence
· Altered nutrition less than body requirements
· Knowledge deficit: prevention, care of ulcer at home, diet
· Research has shown that prevention is the key
· Screen for high risk patients
· Keep the linen smooth
· Keep the patient clean and dry
· Relieve the pressure by turning q2h