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Skin Integrity. Module B (Lab). Class Objectives. Describe kinds of hygienic care nurses provide to patients Identify factors influencing personal hygiene Identify normal and abnormal findings obtained during inspection and palpation of the skin, feet, nails, mouth, hair, and eyes.

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Skin integrity

Skin Integrity

Module B (Lab)


Class objectives
Class Objectives

  • Describe kinds of hygienic care nurses provide to patients

  • Identify factors influencing personal hygiene

  • Identify normal and abnormal findings obtained during inspection and palpation of the skin, feet, nails, mouth, hair, and eyes


Continued objectives
Continued Objectives

  • Describe various types of baths

  • Describe steps in perineal and genital care

  • Identify safety and comfort measures underlying bed-making procedures

  • Describe specific ways in which nurses assist hospitalized clients with oral hygiene


Major functions of the skin
Major Functions of the Skin

  •  Protects body

  •  Helps regulate body temperature

  •  Transmits sensation through nerve receptors

  •  An excretory organ

  • helps maintain H20; and electrolyte balance

  •  Produces and absorbsvitamin D


Skin epidermal layers
Skin: Epidermal Layers

  • Two Main Layers

    • Epidermis (Outer Layer)

    • Dermis (Inner Layer)


Assessment
Assessment

  • Baseline and Continual assessment provide critical information about the client’s skin integrity and the increased risk for pressure ulcer development.


Predictive measures
Predictive Measures

  • A nurse must detect clients at risk for impaired skin integrity early in their assessment

  • During bath need to check for skin breakdown or eruption of lesions


Skin care
Skin Care

  • Developmental Changes/ age and ability influences one’s skin care practices

    • Newborn

    • Toddler

    • Older Adult


Cultural considerations
Cultural Considerations

  • Hygiene practices vary considerably among different cultures

  • Some worry about hot/cold imbalances as a cause of illness

  • Some may be avoided with body conditions


Continued
Continued

  • No s/s of pressure sores

  • No s/s of dryness, flaking, itching, or burning

  • No s/s ischemia, hyperemia or necrosis or excoriation

  • Blanching – pale white not healthy


Continued1
Continued

  • Problems: Immobility, skin breakdown, and or paralyses

  • Causes: Injury, immobility, and intubation

  • Assessments: Include integrity, character of skin, ROM of joints, development of deformities


Assessment1
Assessment

  • Assessment of risk or contributing factors associated with skin breakdown should be determined from the patient’s history


Risk factors

Local Risk

Mechanical

Traumal

Ischemia

Dry Tissue

Systemic Risk

Elderly

Immobility

Malnutrition

Risk Factors


Perineal skin compromise

Local Risks

Incontinence

Inadequate hygiene

Mechanical trauma

Systemic Risks

Recent antibiotic use

Elderly

Malnutrition

Perineal Skin Compromise


Assessment of the skin
Assessment of the Skin

  • Color

  • Temperature

  • Sensation(pain,itching)

  • Hydration (dry, cracked, moist)

  • Tissue consistency (boggy, firm)


Continued2
Continued

  • Normal Findings

    • Skin color varies from person to person

    • Color uniform/Sun exposed areas darker

    • Calluses appear yellow

    • Nevi (moles) can be normal findings


Continued3
Continued

  • Abnormal Findings

    • Color changes in moles

    • Pale shiny skin may indicate decreased peripheral circulation or DM

    • Localized hemorrhages into cutaneous tissue


Skin care1
Skin Care

  • Provide skin care every 4 hours

  • Turn the patient every 2-4 hours

  • Provide mouth care every 2-4 hours

  • Monitor for signs and symptoms of skin breakdown

  • Institute precautions and skin treatment as needed


Pressure ulcers
Pressure Ulcers

  • Pressure ulcers are also called decubitus ulcers, pressure sores, bedsores, or distortion sores

  • Caused by unrelieved pressure ( a compressing downward force on a body area) that results in damage to underlying tissue.


Etiology of pressure ulcers
Etiology of Pressure Ulcers

  • Localized ischemia, deficiency in the blood supply to the tissue.

  • Occur mainly over bony prominences, after skin has been compressed it appears pale.


Risk factors1
Risk Factors

  • Friction is a force acting parallel to the skin surface. For example, sheets rubbing against skin create friction.

  • Shearing force is combination of friction and pressure.


Risk factors2
Risk Factors

  • Immobility refers to reduction and amount and control of movement a person has.

  • Generally prolonged inadequate nutrition causes weight loss, muscle atrophy, and loss of SQ tissue.


Risk factors3
Risk Factors

  • Fecal and urinary incontinence. Moisture from incontinence promotes skin maceration (tissue softened by prolonged wetting or soaking)


Risk factors4
Risk Factors

  • Decrease mental status

  • Diminished sensation

  • Excessive body heat


Risk factors5
Risk Factors

  • The aging process brings about several changes in the skin:

    • Loss of lean body mass

    • Generalized thinning of the epidermis

    • Decrease strength and elasticity


Mobility
Mobility

  • Monitor joint ROM and provide ROM exercises every 4 hours

  • Unconscious patient should be repositioned every 1-2 hours

    • Never place an unconscious patient in a supine position. Why?????


The skin and aging
The Skin and Aging

  • Wrinkling

  • Thinning

  • Decreased muscle tone

  • Fragile and transparent

  • Delayed wound healing

  • Very Dry/ “Age Spots”


Assessment of light skinned individuals
Assessment of Light- Skinned Individuals

  • Pallor- generalized

  • Cyanosis- dusky blue

  • Erythema- bright red, pink

  • Jaundice- yellow-orange, yellow sclera


Assessment of dark skinned individual
Assessment of Dark-Skinned Individual

  • Pallor- yellow-brown, dull, ashen

  • Cyanosis- dark, dull, gray

  • Erythema- purpulish tint, nailbeds cherry red, palpate to identify warmth

  • Jaundice- sclera


Skin lesions
Skin Lesions

  • Primary skin lesions are those that appear in response to some change in the external or internal environment of the skin


Continued4
Continued

  • Secondary lesions are those that do not appear initially but result from modifications such as chronicity, trauma, or infection or primary lesion.


Characteristics of skin lesions
Characteristics of Skin Lesions

  • Color

  • Associated pain, redness, heat, swelling

  • Size and location

  • Pattern of eruption (macular, papular, scaling, oozing, etc)

  • Distribution (linear, circular, symmetric)


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