Transcript The Patient ’s Skin

“Nurse, I See RED…..”
Maintaining skin integrity, it
can be done!
Developed by: Carol Balcavage, RN, WOCN, 2004
The Audience
This education program was
designed for the caregiver
who spends the most time at
the patient’s bedside . . .
“The Nursing Assistant”
Objectives
A. The learner will identify the cause of pressure
ulcers.
B. The learner will identify factors that contribute
to the development of a pressure ulcer.
C. The learner will identify the role of the Nursing
Assistant in prevention of pressure ulcers.
The Patient’s Skin
• Largest organ in the body, equals
12-15% of body weight and receives one
third of the body’s circulating blood volume
• Functions
– Protection
– Thermoregulation
– Sensation
– Metabolism
Maintaining Skin Integrity
• Is everyone’s responsibility
• Patient’s first line of defense from infection
• Many forms of skin integrity issues
– Bruises, skin tears, cracks, shearing,
erosions, scratches, blisters, pressure ulcers
– Hospital acquired pressure ulcers are of great
concern
What is a Pressure Ulcer?
• Any injury caused by unrelieved pressure
that damages the skin and underlying
tissue (fat, muscle, bone). Also called
decubitus ulcers, pressure sores or bed
sores
• Severity ranges from reddening of skin to
deep craters extending to muscle and bone
Why are Pressure Ulcers a Problem?
• Pressure ulcers can produce poor
outcomes for patients including loss of a
limb or even death
• Pressure ulcers are costly
– Increased length of stay
– Added hospital costs
– Additional recovery time
– Pain
– Potential for litigation
Risk Factors
• Moist skin
– Perspiration
– Incontinence
– Wound drainage
• Limited activity and mobility
• Inability to change position independently
in bed or in chair
• Assistance required to get out of bed
• Assistance required to walk
Risk Factors
Loss of sensory perception
– Paralysis (loss of voluntary motion and/or
sensation)
– Neuropathy (“pins & needles” sensation in
affected limb, decrease in sensation)
– Decrease in mental awareness
Risk Factors
• Altered blood flow
– Decreased flow of blood to extremities
• Vascular patients
• Diabetic patients
– Edema
– Hypotensive episode (low BP)
Risk Factors
• Friction and Shearing
– Friction – abrasion of the top layer of skin
– Shearing – the skin separating from
underlying tissues
Risk Factors
• Poor nutrition
• Poor hydration
What Does a Pressure Ulcer Look Like?
What Does a Pressure Ulcer Look Like?
• There are four stages of
pressure ulcer plus unstageable
– Stage I: the ulcer appears as a
defined area of persistent redness
in lightly pigmented skin, whereas
in darker skin tones, the ulcer may
appear with persistent red, blue, or
purple hues
Special Consideration for
Pigmented Skin
• Check skin compared to an adjacent
or opposite area on the body
– Skin temperature (warmth or coolness)
– Tissue consistency (firm or boggy feel)
– Sensation (pain or itching)
What Does a Pressure Ulcer Look Like?
• Stage II: ulcer is superficial and
presents clinically as an abrasion,
blister or shallow crater
• Stage III: full thickness of skin is
lost, exposing the subcutaneous
tissue
• Stage IV: full thickness of skin and
subcutaneous tissue is lost,
exposing muscle or bone
What Does a Pressure Ulcer Look Like?
Unstageable: ulcer is covered with
dead tissue which may be black,
brown or yellow
What Can You Do to Prevent
Pressure Ulcers?
• Each person plays an important role
• Communication and timely reporting is critical
• Other resources are also available such as the
patient’s family and friends, the chaplain,
volunteers and the WOC/ET nurse
• However, it is the “Nursing Assistant” who
spends the most time with the patient and who
can make the biggest difference in preventing
pressure ulcers
Prevention: Decrease Excessive Moisture
• Good skin care
– Bathe patient daily paying particular
attention to skin folds and perineal tissues
– Use skin cleansers with a low pH and skin
protectant on all incontinent patients and
patients who use a bedpan
– Place absorbent material between the skin
folds of obese patients
Prevention: Decrease Moisture
• Good Skin Care
– Limit use of diapers to patients who are out of
bed or who have large amounts of urine or
diarrhea at one time
– Check incontinent patients frequently
– Discuss a toileting schedule with the RN
– Avoid plastic barriers and sheepskin
– Communicate any signs of redness to RN
Prevention
Sensory Perception
– Inspect patient’s skin for areas of redness
with every position change
– Avoid massaging or rubbing bony
prominences (Use a gentle touch when
cleansing skin and applying ointments)
– Turn and reposition every two hours
(minimum)
– Elevate heels off of bed surface
– Check position of foot in the heel protection
device and reposition as necessary
Prevention
Sensory Perception
• Remove compression stockings for ½ hour
twice each day and check heels. If patient is at
risk for heel breakdown, check more frequently
• Perform active and passive range of motion
(ROM) of all involved extremities
Prevention: Activity/Mobility
• Encourage patient to change position
frequently or turn and reposition
patient every two hours
• If patient is not moving because of
poor pain control, discuss with the RN
• Promote ambulation at regular
intervals (consider PT consult if
patient has difficulty with mobility)
Prevention: Activity/Mobility
• Out of bed to chair no longer than two hours at
one sitting
• Reposition in chair after one hour. If patient is
able to do so, remind to shift position every 15
minutes
Hint: Suggest that position be shifted each time there is a
commercial on TV
• Use chair cushion if patient is at risk
Prevention: Altered Circulation
• Report the following unexpected changes
to the RN:
– Change in vital signs and color
– Change in temperature of skin surfaces
– Decrease in urine output
– Swelling in any body tissues
Prevention: Altered Circulation
• Keep in mind that patients with altered
circulation are susceptible to skin damage
from heat and cold from items such as:
– Heating pads
– Hot packs
– Cold packs
Prevention: Friction/Shearing
• Use moisturizers on dry skin surfaces where
applicable and use a bathing system that
incorporates emollients like Vitamin E and
Aloe
• Assess need for assistive devices (heel
protectors, extra pillows)
• Use turning and transfer aids (i.e., lift sheets,
trapeze)
Prevention: Friction/Shearing
• Prevent shearing by maintaining bed
at 30 degrees or less and gatch knees
when possible
• Have patient use a trapeze when indicated
• When using lift sheet to move patient to top of
bed
• Avoid dragging any part of patient’s body
– Put socks on patient’s feet
– Ask patient to bend knees and to push
against bed surface
Prevention: Friction/Shearing
• Powder bedpan edges before placing patient
on bedpan
• Pad patient’s buttocks and or transfer board
when getting patient in and out of bed with
transfer board
• Use elbow protectors when indicated
• Maintain proper positioning in chair
Prevention: Nutrition & Hydration
• Monitor weight on admission and weekly
• Monitor fluid status, I & O as appropriate
• Monitor/encourage nutritional intake
recommendations (target: meal completion
over 75%)
• Accurately record calorie counts
• Give patient nutritional supplements as
ordered
Prevention: Nutrition & Hydration
• Provide patient with hand wipes before
and after meals. Also provide opportunity
to brush teeth
• Whenever possible, get patient out of bed
for meals
PREVENTION is key!
Review
Now let’s test your
knowledge
Select the best answer
A. A pressure ulcer is a surgical wound.
B. A patient with poor circulation is not at
risk for developing a pressure ulcer.
C. Pressure ulcers are caused by
unrelieved pressure.
D. No one develops a pressure ulcer at my
hospital.
Select the best answer
A. A patient with reduced sensation in his
feet is at risk for developing a heel ulcer.
B. Good nutrition leads to bedsores.
C. Moist skin due to perspiration is not a
risk factor.
D. A patient who is paralyzed is not at risk
for developing a pressure sore.
Select the best answer
A. I really don’t worry about pressure ulcers,
that’s the nurse’s job.
B. All patient’s have red heels.
C. I report any reddened area to the RN.
D. I check my incontinent patients every
four hours.
Select the best answer
A. I do not need to report every red mark
that my patient gets on his skin to the
RN.
B. The RN is the only one who can prevent
pressure ulcers.
C. A little pressure sore on my patient’s foot
is not very important.
D. It takes team work to prevent pressure
ulcers and I’m a key player on that team.
Answer Key
C. Pressure ulcers are caused by
unrelieved pressure.
A. A patient with reduced sensation in his
feet is at risk for developing a heel ulcer.
C. I report any reddened area to the RN.
D. It takes team work to prevent pressure
ulcers and I’m a key player on that team.
References
Ayello EA, Baranski S, Lyder CH, Cuddingan J. Pressure ulcers. In:Baranski S
and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA:
Lippincott Williams & Wilkins: 2004. p 240-70.
Calianno C, Assessing and preventing Pressure Ulcers. Adv Skin Wound Care;
2000; 13(5):244-246.
Hess CT. Skin Care Basics..Adv Skin Wound Care 2000; 13(3):127-129.
Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure
Ulcers in Adults:Prediction and Prevention. Cliical PracticeGuideline,No.3 AHCPR
Publication No.
92-0047. Rockville,MD:Agency for Health Care Policy and Research; May 1992.
Ratcliff CR,WOCN’s Evidence-Based Pressure Ulcer Guideline. Adv Skin Wound
Care 2005; 18(4):204-207.
Zulkowski,KM, Tellez R, van Rijswijk L. Documentation with MDS Section M: Skin
Condition. Adv Skin Wound Care 2001; 14(2):81-89.
Lehigh Valley Hospital
Allentown, PA
Developed by:
Carol Balcavage, RN, WOCN, 2005