THE SKIN 20:2 Pages LEQ: How does monitoring the patients skin effect the overall outcome of their care?

SKIN STRUCTURES Average Adult = 3,000 square inches Seven-fold expansion from birth Weighs approximately 6 pounds Receives approximately 1/3 of the body’s blood supply Significant changes occur to the skin as a result of aging process

NORMAL SKIN Acid pH Average Adult = 3,000 square inches Seven-fold expansion from birth Weighs approximately 6 pounds Receives approximately 1/3 of the body’s blood supply Significant changes occur to the skin as a result of aging process

FUNCTIONS ProtectionThermoregulationSensationCommunication

AGING Normal Skin Changes with Aging Loss of Subcutaneous Tissue Thinning of the Dermis Less Elastic Less Oils, Moisture Less Cohesion between Epidermis and Dermis Less Resistance to Changes in Temperature Changes in Hair Color and Distribution

BRADEN SCALE

COSTS B I L L I O N S !!!!!

THE GOAL IS PREVENTION Assessment and monitoring Turning and re-positioning Addressing nutritional problems Teaching patient and family Moisturizing to increase elasticity Managing incontinence Special beds

IDENTIFYING A PRESSURE ULCER Pressure ulcers are areas of localized tissue destruction caused by the compression of soft tissue over a boney prominence and an external surface for a prolonged period of time

PressureUlcerSites

STAGE I PRESSURE ULCER An observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in in skin temperature, tissue consistency or sensation.

STAGING PRESSURE ULCERS STAGE I

NOT A STAGE I

STAGE II Partial thickness loss of skin involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

STAGE II PRESSURE ULCER

MORE STAGE II ULCERS

STAGE III PRESSURE ULCER Full-thickness tissue loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

STAGE III

STAGE III PRESSURE ULCER

STAGE IV PRESSURE ULCERS Full-thickness tissue loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be present.

STAGE IV PRESSURE ULCER

Clinical 20.2 A, B, C, D, E, F, G, ( Pages )