SKIN INTEGRITY

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SKIN INTEGRITY

• SHARON HARVEY
• 23/03/04

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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

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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?

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SKIN INTEGRITY

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

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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

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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

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CAUSES OF PRESSURE ULCERS

• INTRINSIC
• EXTRINSIC

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INTRINSIC FACTORS

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

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EXTRINSIC FACTORS

• POOR HYGIENE
• POOR POSITIONING
• PRESSURE
• SHEARING FORCES
• TRAUMA OR FRICTION
• MOISTURE

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VULNERABLE SKIN
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(No Transcript)
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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

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PRESSURE AREA GRADINGGRADE 1

• DISCOLOURATION OF INTACT SKIN EITHER
  NON-BLANCHING ERYTHEMA, OR BLUE/BLACK BRUISING

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GRADE 2

• PARTIAL THICKNESS SKIN LOSS INVOLVING
  EPIDERMIS/DERMIS

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GRADE 3

• FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO
  SUBCUTANEOUS TISSUE

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GRADE 4

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

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NECROTIC TISSUE

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

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PRESSURE ULCER HEALING PROCESS

• 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

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(No Transcript)
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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

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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.

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DOCUMENTATION

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

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PROPERTIES OF PRESSURE RELIEVING EQUIPMENT

• PRESSURE DISTRIBUTION
• CONFORMITY
• STABILITY
• REDUCED SHEAR FORCES
• HEAT REDUCTION
• MOISTURE ABSORPTION
• FIRE RETARDANT
• WATERPROOF

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TYPES OF PRESSURE RELIEVING EQUIPMENT

• STATIC AIR CUSHIONS / MATTRESSES
• FOAM CUSHIONS / MATTRESSES
• GEL CUSHIONS / MATTRESSES
• WATER CUSHIONS / MATTRESSES

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SELECTION OF PRESSURE RELIEVING AIDS

• HOW DO WE MAKE A CHOICE ABOUT WHAT MATTRESS /
  CUSHION WE USE?
• PATIENT COMPLIANCE
• PATIENTS NEEDS
• MEDICAL CONDITIONS

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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

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REMEMBER

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

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ANY QUESTIONS????