SKIN INTEGRITY
SHARON HARVEY
23/03/04
LEARNING OUTCOMES
THE STUDENT SHOULD BE ABLE TO:
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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
PHYSIOLOGY OF THE SKIN
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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?
SKIN INTEGRITY
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WHAT IS IT?
DEFINITION OF INTEGRITY IS
WHOLENESS
ORIGINAL PERFECT CONDITION
UNBROKEN STATE
IT IS A KEY CONCERN FOR NURSES
PRESSURE ULCER
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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
ASSESSMENT OF SKIN INTEGRITY
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AIM
TO MINIMISE RISK AND TREAT
BREAKDOWN TO PREVENT FURTHER
PROBLEMS IF AT ALL POSSIBLE
USE OF RECOGNISED AND APPROPRIATE
ASSESSMENT TOOL
CAUSES OF PRESSURE ULCERS
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INTRINSIC
EXTRINSIC
INTRINSIC FACTORS
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AGE
NUTRITIONAL STATUS
INCREASE OR DECREASE IN BODY WEIGHT
CIRCULATORY STATUS
IMMOBILITY
INCONTINENCE
DEPENDENCE LEVEL
MENTAL AWARENESS
CONCURRENT DISEASE OR INFECTION
EXTRINSIC FACTORS
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POOR HYGIENE
POOR POSITIONING
PRESSURE
SHEARING FORCES
TRAUMA OR
FRICTION
MOISTURE
VULNERABLE SKIN
PREVENTING PRESSURE ULCERS
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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
PRESSURE AREA GRADING
GRADE 1
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DISCOLOURATION OF
INTACT SKIN –
EITHER NONBLANCHING
ERYTHEMA, OR
BLUE/BLACK
BRUISING
GRADE 2
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PARTIAL THICKNESS
SKIN LOSS
INVOLVING
EPIDERMIS/DERMIS
GRADE 3
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FULL THICKNESS
SKIN LOSS
INVOLVING DAMAGE
TO SUBCUTANEOUS
TISSUE
GRADE 4
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FULL THICKNESS,
WITH EXTENSIVE
DESTUCTION
EXTENDING TO
UNDERLYING BONE
OR TENDON
(REID AND MORISON
1994)
NECROTIC TISSUE
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THIS IS AN AREA OF
SKIN THAT HAS
COMPLETELY DIED
IT CAN BE
SURGICALLY
DEBRIDED
PRESSURE ULCER HEALING
PROCESS
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STAGE 1
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STAGE 2
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STAGE 3
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STAGE 4
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INFLAMMATORY
STAGE 3-5 DAYS
DESTRUCTIVE PHASE
1-6 DAYS
PROLIFERATIVE
STAGE 3-24 DAYS
MATURATION STAGE
24-365 DAYS
AIM OF MANAGEMENT
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CONTROL INTRINSIC FACTORS
ELIMINATE EXTRINSIC FACTORS
COMPLETE HEALING MAY ONLY BE
ACHIEVED BY RECONSTRUCTIVE
SURGERY
REMEMBER CONSIDER ALL PATIENTS TO
BE AT RISK
WHO IS AT RISK OF PRESSURE
SORES?
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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.
DOCUMENTATION
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CLEAR / PRECISE
RECORD STAGE OF PRESSURE SORE
DIMENSIONS, POSITION
RISK ASSESSMENT TOOL USED AND
SCORE
NURSING CARE PLAN / EVALUATION
PROPERTIES OF PRESSURE
RELIEVING EQUIPMENT
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PRESSURE DISTRIBUTION
CONFORMITY
STABILITY
REDUCED SHEAR FORCES
HEAT REDUCTION
MOISTURE ABSORPTION
FIRE RETARDANT
WATERPROOF
TYPES OF PRESSURE RELIEVING
EQUIPMENT
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STATIC AIR CUSHIONS / MATTRESSES
FOAM CUSHIONS / MATTRESSES
GEL CUSHIONS / MATTRESSES
WATER CUSHIONS / MATTRESSES
SELECTION OF PRESSURE
RELIEVING AIDS
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HOW DO WE MAKE A CHOICE ABOUT
WHAT MATTRESS / CUSHION WE USE?
PATIENT COMPLIANCE
PATIENT’S NEEDS
MEDICAL CONDITIONS
SCENARIO WORK
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WHAT ARE THE GOALS OF WOUND
MANAGEMENT IN THIS CASE?
WHAT LOCAL AND MORE GENERAL
PATIENT FACTORS ARE LIKELY TO LEAD
TO DELAYED HEALING
REMEMBER
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PRESSURE SORES ARE AN INDICATION
OF INCORRECT NURSING CARE
THEY ARE PREVENTABLE
SHOULD NEVER OCCUR
COST THE NHS MILLIONS £’S EACH YEAR
ANY QUESTIONS????