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SKIN INTEGRITY

SKIN INTEGRITY. SHARON HARVEY 23/03/04. LEARNING OUTCOMES THE STUDENT SHOULD BE ABLE TO:-. ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR COMPONENTS OF THE SKIN EXPLAIN THE INTRINSIC AND EXTRINSIC RISK FACTORS THAT CAUSE PRESSURE DAMAGE

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SKIN INTEGRITY

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  1. SKIN INTEGRITY SHARON HARVEY 23/03/04

  2. LEARNING OUTCOMESTHE STUDENT SHOULD BE ABLE TO:- • ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR COMPONENTS OF THE SKIN • EXPLAIN THE INTRINSIC AND EXTRINSIC RISK FACTORS THAT CAUSE PRESSURE DAMAGE • 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 • 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 IS THE EPIDERMIS COMPOSED OF ? • WHAT ACCESSORY STRUCTURES ARE FOUND IN THE EPIDERMIS? • WHAT IS THE FUNCTION OF THE EPIDERMIS? • WHAT ARE THE CELLS ARE FOUND IN THE DERMIS? • WHAT FIBRES ARE FOUND WITHIN THE DERMIS? • WHAT IS THE FUNCTION OF THE DERMIS? • WHAT DOES THE HYPODERMIS CONSIST OF? • WHAT ARE THE OVERALL FUNCTIONS OF THE SKIN?

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

  5. PRESSURE ULCER • IS DEFINED BY MALLET (2000) AS:- • “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 • THEY CAUSE PAIN AND DISCOMFORT, DELAY REHABILITATION AND CAN CAUSE DISABILITY AND DEATH • VERY EXPENSIVE FOR THE NHS

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

  7. CAUSES OF PRESSURE ULCERS • INTRINSIC • EXTRINSIC

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

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

  10. VULNERABLE SKIN

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

  12. DISCOLOURATION OF INTACT SKIN – EITHER NON-BLANCHING ERYTHEMA, OR BLUE/BLACK BRUISING PRESSURE AREA GRADINGGRADE 1

  13. GRADE 2 • PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS/DERMIS

  14. FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO SUBCUTANEOUS TISSUE GRADE 3

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

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

  17. STAGE 1 STAGE 2 STAGE 3 STAGE 4 INFLAMMATORY STAGE 3-5 DAYS DESTRUCTIVE PHASE 1-6 DAYS PROLIFERATIVE STAGE 3-24 DAYS MATURATION STAGE 24-365 DAYS PRESSURE ULCER HEALING PROCESS

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

  19. 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. • There are several risk assessment scales • such as the Norton, Braden and Waterlow • Scales which, together with clinical • judgement, can help identify those at risk • of developing pressure sores.

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

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

  22. TYPES OF PRESSURE RELIEVING EQUIPMENT • STATIC AIR CUSHIONS / MATTRESSES • FOAM CUSHIONS / MATTRESSES • GEL CUSHIONS / MATTRESSES • WATER CUSHIONS / MATTRESSES

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

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

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

  26. ANY QUESTIONS????

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