SKIN INTEGRITYSKIN INTEGRITY

SHARON HARVEYSHARON HARVEY23/03/0423/03/04

LEARNING OUTCOMESLEARNING OUTCOMESTHE STUDENT SHOULD BE ABLE THE STUDENT SHOULD BE ABLE

TO:-TO:- ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR ILLUSTRATE THE STRUCTURE AND FUNCTION OF MAJOR

COMPONENTS OF THE SKIN COMPONENTS OF THE SKIN EXPLAIN THE INTRINSIC AND EXTRINSIC RISK FACTORS EXPLAIN THE INTRINSIC AND EXTRINSIC RISK FACTORS

THAT CAUSE PRESSURE DAMAGETHAT CAUSE PRESSURE DAMAGE PERFORM A PRESSURE DAMAGE RISK ASSESSMENT TOOL PERFORM A PRESSURE DAMAGE RISK ASSESSMENT TOOL

TO A CASE STUDY TO A CASE STUDY USE A PRESSURE DAMAGE GRADING TOOL TO CLASSIFY USE A PRESSURE DAMAGE GRADING TOOL TO CLASSIFY

WOUND EXHIBITS INTO CATEGORIES, USING A RECOGNISED WOUND EXHIBITS INTO CATEGORIES, USING A RECOGNISED WOUND CLASSIFICATION SCALE AND ACCURATELY RECORD WOUND CLASSIFICATION SCALE AND ACCURATELY RECORD AND DOCUMENTAND DOCUMENT

EXPLAIN THE LINKAGE OF GOOD HYGIENE, CORRECT EXPLAIN THE LINKAGE OF GOOD HYGIENE, CORRECT MOVING AND HANDLING AND NUTRITION TO PREVENTING MOVING AND HANDLING AND NUTRITION TO PREVENTING PRESSURE DAMAGEPRESSURE DAMAGE

PHYSIOLOGY OF THE SKINPHYSIOLOGY OF THE SKIN WHAT ARE THE THREE LAYERS OF THE SKIN WHAT ARE THE THREE LAYERS OF THE SKIN

CALLED?CALLED? WHAT IS THE EPIDERMIS COMPOSED OF ?WHAT IS THE EPIDERMIS COMPOSED OF ? WHAT ACCESSORY STRUCTURES ARE FOUND IN THE WHAT ACCESSORY STRUCTURES ARE FOUND IN THE

EPIDERMIS?EPIDERMIS? WHAT IS THE FUNCTION OF THE EPIDERMIS?WHAT IS THE FUNCTION OF THE EPIDERMIS? WHAT ARE THE CELLS ARE FOUND IN THE DERMIS?WHAT ARE THE CELLS ARE FOUND IN THE DERMIS? WHAT FIBRES ARE FOUND WITHIN THE DERMIS?WHAT FIBRES ARE FOUND WITHIN THE DERMIS? WHAT IS THE FUNCTION OF THE DERMIS?WHAT IS THE FUNCTION OF THE DERMIS? WHAT DOES THE HYPODERMIS CONSIST OF?WHAT DOES THE HYPODERMIS CONSIST OF? WHAT ARE THE OVERALL FUNCTIONS OF THE SKIN?WHAT ARE THE OVERALL FUNCTIONS OF THE SKIN?

SKIN INTEGRITYSKIN INTEGRITY WHAT IS IT?WHAT IS IT? DEFINITION OF INTEGRITY ISDEFINITION OF INTEGRITY IS WHOLENESSWHOLENESS ORIGINAL PERFECT CONDITIONORIGINAL PERFECT CONDITION UNBROKEN STATEUNBROKEN STATE IT IS A KEY CONCERN FOR NURSESIT IS A KEY CONCERN FOR NURSES

PRESSURE ULCERPRESSURE ULCER IS DEFINED BY MALLET (2000) AS:-IS DEFINED BY MALLET (2000) AS:- ““ANY AREA OF DAMAGE TO THE SKIN OR ANY AREA OF DAMAGE TO THE SKIN OR

UNDERLYING TISSUE CAUSED BY DIRECT UNDERLYING TISSUE CAUSED BY DIRECT PRESSURE OR SHEARING FORCE”PRESSURE OR SHEARING FORCE”

IT FORMS AS A RESULT OF THE DISTORTING OF IT FORMS AS A RESULT OF THE DISTORTING OF CAPILLARIES AND CUTTING OFF BLOOD SUPPLY CAPILLARIES AND CUTTING OFF BLOOD SUPPLY FOR A CRITICAL LENGTH OF TIMEFOR A CRITICAL LENGTH OF TIME

THEY CAUSE PAIN AND DISCOMFORT, DELAY THEY CAUSE PAIN AND DISCOMFORT, DELAY REHABILITATION AND CAN CAUSE DISABILITY REHABILITATION AND CAN CAUSE DISABILITY AND DEATHAND DEATH

VERY EXPENSIVE FOR THE NHSVERY EXPENSIVE FOR THE NHS

ASSESSMENT OF SKIN ASSESSMENT OF SKIN INTEGRITYINTEGRITY

AIMAIM TO MINIMISE RISK AND TREAT TO MINIMISE RISK AND TREAT

BREAKDOWN TO PREVENT FURTHER BREAKDOWN TO PREVENT FURTHER PROBLEMS IF AT ALL POSSIBLEPROBLEMS IF AT ALL POSSIBLE

USE OF RECOGNISED AND USE OF RECOGNISED AND APPROPRIATE ASSESSMENT TOOLAPPROPRIATE ASSESSMENT TOOL

CAUSES OF PRESSURE CAUSES OF PRESSURE ULCERSULCERS

INTRINSICINTRINSIC EXTRINSICEXTRINSIC

INTRINSIC FACTORS INTRINSIC FACTORS AGEAGE NUTRITIONAL STATUSNUTRITIONAL STATUS INCREASE OR DECREASE IN BODY WEIGHTINCREASE OR DECREASE IN BODY WEIGHT CIRCULATORY STATUSCIRCULATORY STATUS IMMOBILITYIMMOBILITY INCONTINENCEINCONTINENCE DEPENDENCE LEVELDEPENDENCE LEVEL MENTAL AWARENESSMENTAL AWARENESS CONCURRENT DISEASE OR INFECTIONCONCURRENT DISEASE OR INFECTION

EXTRINSIC FACTORSEXTRINSIC FACTORS POOR HYGIENEPOOR HYGIENE POOR POSITIONINGPOOR POSITIONING PRESSUREPRESSURE SHEARING FORCESSHEARING FORCES TRAUMA OR TRAUMA OR

FRICTIONFRICTION MOISTUREMOISTURE

VULNERABLE SKINVULNERABLE SKIN

PREVENTING PRESSURE PREVENTING PRESSURE ULCERSULCERS

ASSESS THE PATIENT FOR RISK FACTORSASSESS THE PATIENT FOR RISK FACTORS ENSURE REGULAR CHANGES OF POSITION TO RELIEVE ENSURE REGULAR CHANGES OF POSITION TO RELIEVE

PRESSUREPRESSURE MAINTAIN GOOD STANDARDS OF HYGIENEMAINTAIN GOOD STANDARDS OF HYGIENE PREVENT MECHANICAL, PHYSICAL OR CHEMICAL INJURYPREVENT MECHANICAL, PHYSICAL OR CHEMICAL INJURY ENSURE ADEQUATE NUTRITION AND HYDRATIONENSURE ADEQUATE NUTRITION AND HYDRATION PROMOTE CONTINENCEPROMOTE CONTINENCE USE DEVICES TO EQUALISE PRESSURE OVER PRESSURE USE DEVICES TO EQUALISE PRESSURE OVER PRESSURE

POINTSPOINTS INSPECT THE SKIN SEVERAL TIMES A DAYINSPECT THE SKIN SEVERAL TIMES A DAY PROMOTE MENTAL ALERTNESS AND ORIENTATIONPROMOTE MENTAL ALERTNESS AND ORIENTATION EDUCATE THE PATIENT, FAMILY AND CARE GIVERS IN EDUCATE THE PATIENT, FAMILY AND CARE GIVERS IN

SKIN CARE MEASURESSKIN CARE MEASURES

PRESSURE AREA GRADINGPRESSURE AREA GRADINGGRADE 1GRADE 1

DISCOLOURATION DISCOLOURATION OF INTACT SKIN – OF INTACT SKIN – EITHER NON-EITHER NON-BLANCHING BLANCHING ERYTHEMA, OR ERYTHEMA, OR BLUE/BLACK BLUE/BLACK BRUISINGBRUISING

GRADE 2GRADE 2 PARTIAL PARTIAL

THICKNESS SKIN THICKNESS SKIN LOSS INVOLVING LOSS INVOLVING EPIDERMIS/DERMISEPIDERMIS/DERMIS

GRADE 3GRADE 3 FULL THICKNESS FULL THICKNESS

SKIN LOSS SKIN LOSS INVOLVING INVOLVING DAMAGE TO DAMAGE TO SUBCUTANEOUS SUBCUTANEOUS TISSUETISSUE

GRADE 4GRADE 4 FULL THICKNESS, FULL THICKNESS,

WITH EXTENSIVE WITH EXTENSIVE DESTUCTION DESTUCTION EXTENDING TO EXTENDING TO UNDERLYING BONE UNDERLYING BONE OR TENDONOR TENDON

(REID AND (REID AND MORISON 1994)MORISON 1994)

NECROTIC TISSUENECROTIC TISSUE THIS IS AN AREA THIS IS AN AREA

OF SKIN THAT HAS OF SKIN THAT HAS COMPLETELY DIEDCOMPLETELY DIED

IT CAN BE IT CAN BE SURGICALLY SURGICALLY DEBRIDEDDEBRIDED

PRESSURE ULCER HEALING PRESSURE ULCER HEALING PROCESSPROCESS

STAGE 1STAGE 1

STAGE 2STAGE 2

STAGE 3STAGE 3

STAGE 4STAGE 4

INFLAMMATORY INFLAMMATORY STAGE 3-5 DAYSSTAGE 3-5 DAYS

DESTRUCTIVE DESTRUCTIVE PHASE 1-6 DAYSPHASE 1-6 DAYS

PROLIFERATIVE PROLIFERATIVE STAGE 3-24 DAYSSTAGE 3-24 DAYS

MATURATION MATURATION STAGE 24-365 STAGE 24-365 DAYSDAYS

AIM OF MANAGEMENTAIM OF MANAGEMENT CONTROL INTRINSIC FACTORSCONTROL INTRINSIC FACTORS ELIMINATE EXTRINSIC FACTORSELIMINATE EXTRINSIC FACTORS

COMPLETE HEALING MAY ONLY BE COMPLETE HEALING MAY ONLY BE ACHIEVED BY RECONSTRUCTIVE ACHIEVED BY RECONSTRUCTIVE SURGERYSURGERY

REMEMBER CONSIDER ALL PATIENTS REMEMBER CONSIDER ALL PATIENTS TO BE AT RISKTO BE AT RISK

WHO IS AT RISK OF PRESSURE WHO IS AT RISK OF PRESSURE SORES?SORES?

Risk will vary from person to person; Risk will vary from person to person; however, in some cases damage to skin however, in some cases damage to skin tissue, (which may lead to tissue, (which may lead to pressurepressure sores) can occur within half an hour.sores) can occur within half an hour.

There are several risk assessment scalesThere are several risk assessment scales such as the Norton, Braden and Waterlowsuch as the Norton, Braden and Waterlow Scales which, together with clinicalScales which, together with clinical judgement, can help identify those at riskjudgement, can help identify those at risk of developing of developing pressurepressure sores. sores.

DOCUMENTATIONDOCUMENTATION CLEAR / PRECISECLEAR / PRECISE RECORD STAGE OF PRESSURE SORERECORD STAGE OF PRESSURE SORE DIMENSIONS, POSITIONDIMENSIONS, POSITION RISK ASSESSMENT TOOL USED AND RISK ASSESSMENT TOOL USED AND

SCORESCORE NURSING CARE PLAN / EVALUATIONNURSING CARE PLAN / EVALUATION

PROPERTIES OF PRESSURE PROPERTIES OF PRESSURE RELIEVING EQUIPMENTRELIEVING EQUIPMENT

PRESSURE DISTRIBUTIONPRESSURE DISTRIBUTION CONFORMITYCONFORMITY STABILITYSTABILITY REDUCED SHEAR FORCESREDUCED SHEAR FORCES HEAT REDUCTIONHEAT REDUCTION MOISTURE ABSORPTIONMOISTURE ABSORPTION FIRE RETARDANTFIRE RETARDANT WATERPROOFWATERPROOF

TYPES OF PRESSURE TYPES OF PRESSURE RELIEVING EQUIPMENTRELIEVING EQUIPMENT

STATIC AIR CUSHIONS / MATTRESSESSTATIC AIR CUSHIONS / MATTRESSES FOAM CUSHIONS / MATTRESSESFOAM CUSHIONS / MATTRESSES GEL CUSHIONS / MATTRESSESGEL CUSHIONS / MATTRESSES WATER CUSHIONS / MATTRESSESWATER CUSHIONS / MATTRESSES

SELECTION OF PRESSURE SELECTION OF PRESSURE RELIEVING AIDSRELIEVING AIDS

HOW DO WE MAKE A CHOICE ABOUT HOW DO WE MAKE A CHOICE ABOUT WHAT MATTRESS / CUSHION WE WHAT MATTRESS / CUSHION WE USE?USE?

PATIENT COMPLIANCEPATIENT COMPLIANCE PATIENT’S NEEDSPATIENT’S NEEDS MEDICAL CONDITIONSMEDICAL CONDITIONS

SCENARIO WORKSCENARIO WORK WHAT ARE THE GOALS OF WOUND WHAT ARE THE GOALS OF WOUND

MANAGEMENT IN THIS CASE?MANAGEMENT IN THIS CASE? WHAT LOCAL AND MORE GENERAL WHAT LOCAL AND MORE GENERAL

PATIENT FACTORS ARE LIKELY TO PATIENT FACTORS ARE LIKELY TO LEAD TO DELAYED HEALINGLEAD TO DELAYED HEALING

REMEMBERREMEMBER PRESSURE SORES ARE AN PRESSURE SORES ARE AN

INDICATION OF INCORRECT NURSING INDICATION OF INCORRECT NURSING CARECARE

THEY ARE PREVENTABLETHEY ARE PREVENTABLE SHOULD NEVER OCCURSHOULD NEVER OCCUR COST THE NHS MILLIONS £’S EACH COST THE NHS MILLIONS £’S EACH

YEARYEAR

ANY QUESTIONS????ANY QUESTIONS????