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SKIN INTEGRITY SHARON HARVEY 23/03/04. LEARNING OUTCOMES THE STUDENT SHOULD BE ABLE TO:- ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR COMPONENTS OF.

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Presentation on theme: "SKIN INTEGRITY SHARON HARVEY 23/03/04. LEARNING OUTCOMES THE STUDENT SHOULD BE ABLE TO:- ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR COMPONENTS OF."— Presentation transcript:

1 SKIN INTEGRITY SHARON HARVEY 23/03/04

2 LEARNING OUTCOMES THE STUDENT SHOULD BE ABLE TO:- ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR COMPONENTS OF THE SKIN ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR COMPONENTS OF THE SKIN EXPLAIN THE INTRINSIC AND EXTRINSIC RISK FACTORS THAT CAUSE PRESSURE DAMAGE EXPLAIN THE INTRINSIC AND EXTRINSIC RISK FACTORS THAT CAUSE PRESSURE DAMAGE PERFORM A PRESSURE DAMAGE RISK ASSESSMENT TOOL TO A CASE STUDY PERFORM A PRESSURE DAMAGE RISK ASSESSMENT TOOL TO A CASE STUDY USE A PRESSURE DAMAGE GRADING TOOL TO CLASSIFY WOUND EXHIBITS INTO CATEGORIES, USING A RECOGNISED WOUND CLASSIFICATION SCALE AND ACCURATELY RECORD AND DOCUMENT USE A PRESSURE DAMAGE GRADING TOOL TO CLASSIFY WOUND EXHIBITS INTO CATEGORIES, USING A RECOGNISED WOUND CLASSIFICATION SCALE AND ACCURATELY RECORD AND DOCUMENT EXPLAIN THE LINKAGE OF GOOD HYGIENE, CORRECT MOVING AND HANDLING AND NUTRITION TO PREVENTING PRESSURE DAMAGE EXPLAIN THE LINKAGE OF GOOD HYGIENE, CORRECT MOVING AND HANDLING AND NUTRITION TO PREVENTING PRESSURE DAMAGE

3 PHYSIOLOGY OF THE SKIN WHAT ARE THE THREE LAYERS OF THE SKIN CALLED? WHAT ARE THE THREE LAYERS OF THE SKIN CALLED? WHAT IS THE EPIDERMIS COMPOSED OF ? WHAT IS THE EPIDERMIS COMPOSED OF ? WHAT ACCESSORY STRUCTURES ARE FOUND IN THE EPIDERMIS? WHAT ACCESSORY STRUCTURES ARE FOUND IN THE EPIDERMIS? WHAT IS THE FUNCTION OF THE EPIDERMIS? WHAT IS THE FUNCTION OF THE EPIDERMIS? WHAT ARE THE CELLS ARE FOUND IN THE DERMIS? WHAT ARE THE CELLS ARE FOUND IN THE DERMIS? WHAT FIBRES ARE FOUND WITHIN THE DERMIS? WHAT FIBRES ARE FOUND WITHIN THE DERMIS? WHAT IS THE FUNCTION OF THE DERMIS? WHAT IS THE FUNCTION OF THE DERMIS? WHAT DOES THE HYPODERMIS CONSIST OF? WHAT DOES THE HYPODERMIS CONSIST OF? WHAT ARE THE OVERALL FUNCTIONS OF THE SKIN? WHAT ARE THE OVERALL FUNCTIONS OF THE SKIN?

4 SKIN INTEGRITY WHAT IS IT? WHAT IS IT? DEFINITION OF INTEGRITY IS DEFINITION OF INTEGRITY IS WHOLENESS WHOLENESS ORIGINAL PERFECT CONDITION ORIGINAL PERFECT CONDITION UNBROKEN STATE UNBROKEN STATE IT IS A KEY CONCERN FOR NURSES IT IS A KEY CONCERN FOR NURSES

5 PRESSURE ULCER IS DEFINED BY MALLET (2000) AS:- IS DEFINED BY MALLET (2000) AS:- “ANY AREA OF DAMAGE TO THE SKIN OR UNDERLYING TISSUE CAUSED BY DIRECT PRESSURE OR SHEARING FORCE” “ANY AREA OF DAMAGE TO THE SKIN OR UNDERLYING TISSUE CAUSED BY DIRECT PRESSURE OR SHEARING FORCE” IT FORMS AS A RESULT OF THE DISTORTING OF CAPILLARIES AND CUTTING OFF BLOOD SUPPLY FOR A CRITICAL LENGTH OF TIME IT FORMS AS A RESULT OF THE DISTORTING OF CAPILLARIES AND CUTTING OFF BLOOD SUPPLY FOR A CRITICAL LENGTH OF TIME THEY CAUSE PAIN AND DISCOMFORT, DELAY REHABILITATION AND CAN CAUSE DISABILITY AND DEATH THEY CAUSE PAIN AND DISCOMFORT, DELAY REHABILITATION AND CAN CAUSE DISABILITY AND DEATH VERY EXPENSIVE FOR THE NHS VERY EXPENSIVE FOR THE NHS

6 ASSESSMENT OF SKIN INTEGRITY AIM AIM TO MINIMISE RISK AND TREAT BREAKDOWN TO PREVENT FURTHER PROBLEMS IF AT ALL POSSIBLE TO MINIMISE RISK AND TREAT BREAKDOWN TO PREVENT FURTHER PROBLEMS IF AT ALL POSSIBLE USE OF RECOGNISED AND APPROPRIATE ASSESSMENT TOOL USE OF RECOGNISED AND APPROPRIATE ASSESSMENT TOOL

7 CAUSES OF PRESSURE ULCERS INTRINSIC INTRINSIC EXTRINSIC EXTRINSIC

8 INTRINSIC FACTORS AGE AGE NUTRITIONAL STATUS NUTRITIONAL STATUS INCREASE OR DECREASE IN BODY WEIGHT INCREASE OR DECREASE IN BODY WEIGHT CIRCULATORY STATUS CIRCULATORY STATUS IMMOBILITY IMMOBILITY INCONTINENCE INCONTINENCE DEPENDENCE LEVEL DEPENDENCE LEVEL MENTAL AWARENESS MENTAL AWARENESS CONCURRENT DISEASE OR INFECTION CONCURRENT DISEASE OR INFECTION

9 EXTRINSIC FACTORS POOR HYGIENE POOR HYGIENE POOR POSITIONING POOR POSITIONING PRESSURE PRESSURE SHEARING FORCES SHEARING FORCES TRAUMA OR FRICTION TRAUMA OR FRICTION MOISTURE MOISTURE

10 VULNERABLE SKIN

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12 PREVENTING PRESSURE ULCERS ASSESS THE PATIENT FOR RISK FACTORS ASSESS THE PATIENT FOR RISK FACTORS ENSURE REGULAR CHANGES OF POSITION TO RELIEVE PRESSURE ENSURE REGULAR CHANGES OF POSITION TO RELIEVE PRESSURE MAINTAIN GOOD STANDARDS OF HYGIENE MAINTAIN GOOD STANDARDS OF HYGIENE PREVENT MECHANICAL, PHYSICAL OR CHEMICAL INJURY PREVENT MECHANICAL, PHYSICAL OR CHEMICAL INJURY ENSURE ADEQUATE NUTRITION AND HYDRATION ENSURE ADEQUATE NUTRITION AND HYDRATION PROMOTE CONTINENCE PROMOTE CONTINENCE USE DEVICES TO EQUALISE PRESSURE OVER PRESSURE POINTS USE DEVICES TO EQUALISE PRESSURE OVER PRESSURE POINTS INSPECT THE SKIN SEVERAL TIMES A DAY INSPECT THE SKIN SEVERAL TIMES A DAY PROMOTE MENTAL ALERTNESS AND ORIENTATION PROMOTE MENTAL ALERTNESS AND ORIENTATION EDUCATE THE PATIENT, FAMILY AND CARE GIVERS IN SKIN CARE MEASURES EDUCATE THE PATIENT, FAMILY AND CARE GIVERS IN SKIN CARE MEASURES

13 PRESSURE AREA GRADING GRADE 1 DISCOLOURATION OF INTACT SKIN – EITHER NON- BLANCHING ERYTHEMA, OR BLUE/BLACK BRUISING DISCOLOURATION OF INTACT SKIN – EITHER NON- BLANCHING ERYTHEMA, OR BLUE/BLACK BRUISING

14 GRADE 2 PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS/DERMIS PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS/DERMIS

15 GRADE 3 FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO SUBCUTANEOUS TISSUE FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO SUBCUTANEOUS TISSUE

16 GRADE 4 FULL THICKNESS, WITH EXTENSIVE DESTUCTION EXTENDING TO UNDERLYING BONE OR TENDON FULL THICKNESS, WITH EXTENSIVE DESTUCTION EXTENDING TO UNDERLYING BONE OR TENDON (REID AND MORISON 1994) (REID AND MORISON 1994)

17 NECROTIC TISSUE THIS IS AN AREA OF SKIN THAT HAS COMPLETELY DIED THIS IS AN AREA OF SKIN THAT HAS COMPLETELY DIED IT CAN BE SURGICALLY DEBRIDED IT CAN BE SURGICALLY DEBRIDED

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19 PRESSURE ULCER HEALING PROCESS STAGE 1 STAGE 1 STAGE 2 STAGE 2 STAGE 3 STAGE 3 STAGE 4 STAGE 4 INFLAMMATORY STAGE 3-5 DAYS INFLAMMATORY STAGE 3-5 DAYS DESTRUCTIVE PHASE 1-6 DAYS DESTRUCTIVE PHASE 1-6 DAYS PROLIFERATIVE STAGE 3-24 DAYS PROLIFERATIVE STAGE 3-24 DAYS MATURATION STAGE DAYS MATURATION STAGE DAYS

20

21 AIM OF MANAGEMENT CONTROL INTRINSIC FACTORS CONTROL INTRINSIC FACTORS ELIMINATE EXTRINSIC FACTORS ELIMINATE EXTRINSIC FACTORS COMPLETE HEALING MAY ONLY BE ACHIEVED BY RECONSTRUCTIVE SURGERY COMPLETE HEALING MAY ONLY BE ACHIEVED BY RECONSTRUCTIVE SURGERY REMEMBER CONSIDER ALL PATIENTS TO BE AT RISK REMEMBER CONSIDER ALL PATIENTS TO BE AT RISK

22 WHO IS AT RISK OF PRESSURE SORES? Risk will vary from person to person; however, in some cases damage to skin tissue, (which may lead to pressure sores) can occur within half an hour. Risk will vary from person to person; however, in some cases damage to skin tissue, (which may lead to pressure sores) can occur within half an hour. There are several risk assessment scales There are several risk assessment scales such as the Norton, Braden and Waterlow such as the Norton, Braden and Waterlow Scales which, together with clinical Scales which, together with clinical judgement, can help identify those at risk judgement, can help identify those at risk of developing pressure sores. of developing pressure sores.

23 DOCUMENTATION CLEAR / PRECISE CLEAR / PRECISE RECORD STAGE OF PRESSURE SORE RECORD STAGE OF PRESSURE SORE DIMENSIONS, POSITION DIMENSIONS, POSITION RISK ASSESSMENT TOOL USED AND SCORE RISK ASSESSMENT TOOL USED AND SCORE NURSING CARE PLAN / EVALUATION NURSING CARE PLAN / EVALUATION

24 PROPERTIES OF PRESSURE RELIEVING EQUIPMENT PRESSURE DISTRIBUTION PRESSURE DISTRIBUTION CONFORMITY CONFORMITY STABILITY STABILITY REDUCED SHEAR FORCES REDUCED SHEAR FORCES HEAT REDUCTION HEAT REDUCTION MOISTURE ABSORPTION MOISTURE ABSORPTION FIRE RETARDANT FIRE RETARDANT WATERPROOF WATERPROOF

25 TYPES OF PRESSURE RELIEVING EQUIPMENT STATIC AIR CUSHIONS / MATTRESSES STATIC AIR CUSHIONS / MATTRESSES FOAM CUSHIONS / MATTRESSES FOAM CUSHIONS / MATTRESSES GEL CUSHIONS / MATTRESSES GEL CUSHIONS / MATTRESSES WATER CUSHIONS / MATTRESSES WATER CUSHIONS / MATTRESSES

26 SELECTION OF PRESSURE RELIEVING AIDS HOW DO WE MAKE A CHOICE ABOUT WHAT MATTRESS / CUSHION WE USE? HOW DO WE MAKE A CHOICE ABOUT WHAT MATTRESS / CUSHION WE USE? PATIENT COMPLIANCE PATIENT COMPLIANCE PATIENT’S NEEDS PATIENT’S NEEDS MEDICAL CONDITIONS MEDICAL CONDITIONS

27 SCENARIO WORK WHAT ARE THE GOALS OF WOUND MANAGEMENT IN THIS CASE? WHAT ARE THE GOALS OF WOUND MANAGEMENT IN THIS CASE? WHAT LOCAL AND MORE GENERAL PATIENT FACTORS ARE LIKELY TO LEAD TO DELAYED HEALING WHAT LOCAL AND MORE GENERAL PATIENT FACTORS ARE LIKELY TO LEAD TO DELAYED HEALING

28 REMEMBER PRESSURE SORES ARE AN INDICATION OF INCORRECT NURSING CARE PRESSURE SORES ARE AN INDICATION OF INCORRECT NURSING CARE THEY ARE PREVENTABLE THEY ARE PREVENTABLE SHOULD NEVER OCCUR SHOULD NEVER OCCUR COST THE NHS MILLIONS £’S EACH YEAR COST THE NHS MILLIONS £’S EACH YEAR

29 ANY QUESTIONS????


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