Presentation on theme: "Maintaining skin integrity, it can be done!"— Presentation transcript:
1 Maintaining skin integrity, it can be done! “Nurse, I See RED…..”Maintaining skin integrity, itcan be done!Developed by: Carol Balcavage, RN, WOCN, 2004
2 “The Nursing Assistant” The AudienceThis education program was designed for the caregiver who spends the most time at the patient’s bedside . . .“The Nursing Assistant”
3 Objectives The learner will identify the cause of pressure ulcers. The learner will identify factors that contribute to the development of a pressure ulcer.The learner will identify the role of the Nursing Assistant in prevention of pressure ulcers.
4 The Patient’s Skin Largest organ in the body, equals 12-15% of body weight and receives one third of the body’s circulating blood volumeFunctionsProtectionThermoregulationSensationMetabolism
5 Maintaining Skin Integrity Is everyone’s responsibilityPatient’s first line of defense from infectionMany forms of skin integrity issuesBruises, skin tears, cracks, shearing, erosions, scratches, blisters, pressure ulcersHospital acquired pressure ulcers are of great concern
6 What is a Pressure Ulcer? Any injury caused by unrelieved pressure that damages the skin and underlying tissue (fat, muscle, bone). Also called decubitus ulcers, pressure sores or bed soresSeverity ranges from reddening of skin to deep craters extending to muscle and bone
7 Why are Pressure Ulcers a Problem? Pressure ulcers can produce poor outcomes for patients including loss of a limb or even deathPressure ulcers are costlyIncreased length of stayAdded hospital costsAdditional recovery timePainPotential for litigation
8 Risk Factors Moist skin Limited activity and mobility PerspirationIncontinenceWound drainageLimited activity and mobilityInability to change position independently in bed or in chairAssistance required to get out of bedAssistance required to walk
9 Risk Factors Loss of sensory perception Paralysis (loss of voluntary motion and/or sensation)Neuropathy (“pins & needles” sensation in affected limb, decrease in sensation)Decrease in mental awareness
10 Risk Factors Altered blood flow Decreased flow of blood to extremities Vascular patientsDiabetic patientsEdemaHypotensive episode (low BP)
11 Risk Factors Friction and Shearing Friction – abrasion of the top layer of skinShearing – the skin separating from underlying tissues
14 What Does a Pressure Ulcer Look Like? There are four stages of pressure ulcer plus unstageableStage I: the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues
15 Special Consideration for Pigmented Skin Check skin compared to an adjacent or opposite area on the bodySkin temperature (warmth or coolness)Tissue consistency (firm or boggy feel)Sensation (pain or itching)
16 What Does a Pressure Ulcer Look Like? Stage II: ulcer is superficial andpresents clinically as an abrasion,blister or shallow craterStage III: full thickness of skin islost, exposing the subcutaneoustissueStage IV: full thickness of skin andsubcutaneous tissue is lost,exposing muscle or bone
17 What Does a Pressure Ulcer Look Like? Unstageable: ulcer is covered withdead tissue which may be black,brown or yellow
18 What Can You Do to Prevent Pressure Ulcers? Each person plays an important roleCommunication and timely reporting is criticalOther resources are also available such as the patient’s family and friends, the chaplain, volunteers and the WOC/ET nurseHowever, it is the “Nursing Assistant” who spends the most time with the patient and who can make the biggest difference in preventing pressure ulcers
19 Prevention: Decrease Excessive Moisture Good skin careBathe patient daily paying particular attention to skin folds and perineal tissuesUse skin cleansers with a low pH and skin protectant on all incontinent patients and patients who use a bedpanPlace absorbent material between the skin folds of obese patients
20 Prevention: Decrease Moisture Good Skin CareLimit use of diapers to patients who are out of bed or who have large amounts of urine or diarrhea at one timeCheck incontinent patients frequentlyDiscuss a toileting schedule with the RNAvoid plastic barriers and sheepskinCommunicate any signs of redness to RN
21 Prevention Sensory Perception Inspect patient’s skin for areas of redness with every position changeAvoid massaging or rubbing bony prominences (Use a gentle touch when cleansing skin and applying ointments)Turn and reposition every two hours (minimum)Elevate heels off of bed surfaceCheck position of foot in the heel protection device and reposition as necessary
22 Prevention Sensory Perception Remove compression stockings for ½ hour twice each day and check heels. If patient is at risk for heel breakdown, check more frequentlyPerform active and passive range of motion (ROM) of all involved extremities
23 Prevention: Activity/Mobility Encourage patient to change position frequently or turn and reposition patient every two hoursIf patient is not moving because of poor pain control, discuss with the RNPromote ambulation at regular intervals (consider PT consult if patient has difficulty with mobility)
24 Prevention: Activity/Mobility Out of bed to chair no longer than two hours at one sittingReposition in chair after one hour. If patient is able to do so, remind to shift position every 15 minutesHint: Suggest that position be shifted each time there is a commercial on TVUse chair cushion if patient is at risk
25 Prevention: Altered Circulation Report the following unexpected changes to the RN:Change in vital signs and colorChange in temperature of skin surfacesDecrease in urine outputSwelling in any body tissues
26 Prevention: Altered Circulation Keep in mind that patients with altered circulation are susceptible to skin damage from heat and cold from items such as:Heating padsHot packsCold packs
27 Prevention: Friction/Shearing Use moisturizers on dry skin surfaces where applicable and use a bathing system that incorporates emollients like Vitamin E and AloeAssess need for assistive devices (heel protectors, extra pillows)Use turning and transfer aids (i.e., lift sheets, trapeze)
28 Prevention: Friction/Shearing Prevent shearing by maintaining bedat 30 degrees or less and gatch kneeswhen possibleHave patient use a trapeze when indicatedWhen using lift sheet to move patient to top of bedAvoid dragging any part of patient’s bodyPut socks on patient’s feetAsk patient to bend knees and to pushagainst bed surface
29 Prevention: Friction/Shearing Powder bedpan edges before placing patient on bedpanPad patient’s buttocks and or transfer board when getting patient in and out of bed with transfer boardUse elbow protectors when indicatedMaintain proper positioning in chair
30 Prevention: Nutrition & Hydration Monitor weight on admission and weeklyMonitor fluid status, I & O as appropriateMonitor/encourage nutritional intake recommendations (target: meal completion over 75%)Accurately record calorie countsGive patient nutritional supplements as ordered
31 Prevention: Nutrition & Hydration Provide patient with hand wipes before and after meals. Also provide opportunity to brush teethWhenever possible, get patient out of bed for meals
33 Now let’s test your knowledge ReviewNow let’s test your knowledge
34 Select the best answer A pressure ulcer is a surgical wound. A patient with poor circulation is not at risk for developing a pressure ulcer.Pressure ulcers are caused by unrelieved pressure.No one develops a pressure ulcer at my hospital.
35 Select the best answerA patient with reduced sensation in his feet is at risk for developing a heel ulcer.Good nutrition leads to bedsores.Moist skin due to perspiration is not a risk factor.A patient who is paralyzed is not at risk for developing a pressure sore.
36 Select the best answerI really don’t worry about pressure ulcers, that’s the nurse’s job.All patient’s have red heels.I report any reddened area to the RN.I check my incontinent patients every four hours.
37 Select the best answerI do not need to report every red mark that my patient gets on his skin to the RN.The RN is the only one who can prevent pressure ulcers.A little pressure sore on my patient’s foot is not very important.It takes team work to prevent pressure ulcers and I’m a key player on that team.
38 Answer Key C. Pressure ulcers are caused by unrelieved pressure. A. A patient with reduced sensation in his feet is at risk for developing a heel ulcer.C. I report any reddened area to the RN.D. It takes team work to prevent pressure ulcers and I’m a key player on that team.
39 ReferencesAyello EA, Baranski S, Lyder CH, Cuddingan J. Pressure ulcers. In:Baranski S and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins: pCalianno C, Assessing and preventing Pressure Ulcers. Adv Skin Wound Care; 2000; 13(5):Hess CT. Skin Care Basics..Adv Skin Wound Care 2000; 13(3):Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults:Prediction and Prevention. Cliical PracticeGuideline,No.3 AHCPR Publication No Rockville,MD:Agency for Health Care Policy and Research; May 1992.Ratcliff CR,WOCN’s Evidence-Based Pressure Ulcer Guideline. Adv Skin Wound Care 2005; 18(4):Zulkowski,KM, Tellez R, van Rijswijk L. Documentation with MDS Section M: Skin Condition. Adv Skin Wound Care 2001; 14(2):81-89.
40 Lehigh Valley Hospital Allentown, PA Developed by:Carol Balcavage, RN, WOCN, 2005