1. Understand nurse aide skills needed to promote skin integrity. Unit B Resident Care Skills Essential Standard NA5.00 Understand nurse aide’s role in providing residents’ hygiene, grooming, and skin care. Indicator 5.02 Understand nurse aide skills needed to promote skin integrity. 15.02Nursing Fundamentals 7243

2. 25.02Nursing Fundamentals 7243 As a direct care giver, the nurse aide will be the key team member in the prevention of pressure ulcers. 5.02 Introduction

3. Nursing Fundamentals 72433 PRESSURE ULCERSAKA:Bedsores Decubitus Ulcers 5.02

4. Nursing Fundamentals 72434 PRESSURE ULCERS Caused by pressure on area of skin that interferes with circulation 5.02

5. Nursing Fundamentals 72435 PRESSURE ULCERS Occur where bones come close to the skin surface or bony prominences. 5.02

6. Nursing Fundamentals 72436 PRESSURE ULCERS –toes, heels, ankles, knees –hips, elbows, shoulders –spine (especially tailbone area) –ears, cheeks, collarbone area –back of head 5.02

7. Nursing Fundamentals 72437 PRESSURE ULCERS Can develop where areas of body rub together and moisture collects, especially in obese residents 5.02

8. Nursing Fundamentals 72438 PRESSURE ULCERS –Under breasts –Between folds of abdomen –Between crease of buttocks –Between thighs 5.02

9. Nursing Fundamentals 72439 PRESSURE ULCERS 1 OUNCE PREVENTION 1 POUND CURE 5.02

10. Nursing Fundamentals 724310 PRESSURE ULCER PREVENTION Keep skin clean and dry! 5.02

11. Nursing Fundamentals 724311 PRESSURE ULCER PREVENTION Keep linen dry and free of wrinkles and objects that cause pressure to the skin! 5.02

12. Nursing Fundamentals 724312 PRESSURE ULCER PREVENTION Clean urine and feces from skin as soon as possible! 5.02

13. Nursing Fundamentals 724313 PRESSURE ULCER PREVENTION Reposition residents at least every two hours! 5.02

14. Nursing Fundamentals 724314 PRESSURE ULCER PREVENTION Make sure clothing and shoes do not bind or constrict! 5.02

15. Nursing Fundamentals 724315 PRESSURE ULCER PREVENTION Pat skin dry when bathing; never scrub. 5.02

16. Nursing Fundamentals 724316 PRESSURE ULCER PREVENTION Encourage adequate nutrition and fluids! 5.02

17. Nursing Fundamentals 724317 PRESSURE ULCER PREVENTION Massage healthy skin and tissue around the area. 5.02

18. Nursing Fundamentals 724318 PRESSURE ULCER PREVENTION Massage skin often. Use light circular stroke to increase circulation. 5.02

19. Nursing Fundamentals 724319 PRESSURE ULCER PREVENTION Use little or no pressure on bony areas. 5.02

20. Nursing Fundamentals 724320 PRESSURE ULCER PREVENTION Do NOT message a white, red, or purple area or put any pressure on it. 5.02

21. Nursing Fundamentals 724321 PRESSURE ULCER PREVENTION Be careful during transfers. Avoid pulling or tearing fragile skin. 5.02

22. Nursing Fundamentals 724322 PRESSURE ULCER PREVENTION Take YOUR jewelry off! This is just like a knife! 5.02

23. Nursing Fundamentals 724323 PRESSURE ULCER PREVENTION Keep YOUR nails short! This is just like a knife! 5.02

24. Nursing Fundamentals 724324 PRESSURE ULCER PREVENTION Keep YOUR nails short! This is safe. 5.02

25. 25 IMMEDIATELY ANY CHANGE IN SKIN CONDITION! 5.02Nursing Fundamentals 7243

26. 26 PRESSURE ULCER PREVENTIVE DEVICES  Bed cradle  Heel and elbow protectors  Flotation pads or cushions  Pillows  Water beds  Alternating pressure mattresses  Eggcrate mattresses 5.02

27. Nursing Fundamentals 724327 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage One - red, darkened or non-blanchable skin, which is still present 30 minutes after pressure relieved 5.02

28. Nursing Fundamentals 724328 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage One position off area and report; do not massage observe every 2 hours and report changes to supervisor 5.02

29. Nursing Fundamentals 724329 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Two - addition of blister-like lesions; skin may be broken 5.02

30. Nursing Fundamentals 724330 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Two position off area at all times,position off area at all times, report need for dressing changesreport need for dressing changes report odor, drainage, any change in sizereport odor, drainage, any change in size 5.02

31. Nursing Fundamentals 724331 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Three - skin tissue is destroyed and fatty tissue may be involved; infection and eschar (scab) may result 5.02

32. Nursing Fundamentals 724332 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Three continue prevention practices report any changes in area 5.02

33. Nursing Fundamentals 724333 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Four - skin, fatty tissue destroyed and muscle and bone involved! 5.02

34. Nursing Fundamentals 724334 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Four report any signs of systemic infection, including but not limited to: report any signs of systemic infection, including but not limited to: wound odorwound odor painpain elevated temperature with confusionelevated temperature with confusion 5.02