Safety & Integumentary
Nursing 110
Key Concepts
Safety:
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Basic human need second to only survival needs
Fundamental to provided safe effective high-quality care.
Nurses play a huge part in client safety in any healthcare setting
Safety Statistics
Importance of Safety
 Accidents, unintentional injuries are the 3rd leading cause of death in the united states
(CDC,2019)
 Disabling Injuries beyond the day of injury
 National Patient Safety Goals
 Yearly publication by "The Joint Commission"
 Creating a culture of safety
 People make the mistakes. Systems set the stage for them.
 All levels of leadership make safety a visible priority and take actions that promote
safety
 American Nursing Association
 Main aim to support patient safety
 Quality and Safety Education for Nurses
 Task force to improve nursing education and competencies
 Safety one of the competencies nursing students should have
Safety Developmental Factors
Infant/Toddler
 Dependent on others for their care
 Love to explore the environment
 Choking risk (highest between 6months-3years)
 Increased risk of ingesting poisonous substances
 Mobility improves- creates greater safety risk
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Identify 3 topics that the nurse could educate parents on Regarding infant/toddler safety
Preschooler
 More prone to accidents at school around pools
 Accidental death- drowning, car accidents, fires and poisoning
 Motor vehicle accidents leading cause of death 1-4 years old
 Need close adult supervision
 Identify 3 topics that the nurse could educate parents on Regarding infant/toddler safety
School Age Child
 Bone and muscle injuries more common
 Stranger Danger
 List interventions that the nurse could include for the school aged child who has suffered a
concussion after a game of flagged foot ball
Adolescent
 More prone to risky behaviors
 Feel they are invincible
 Motor vehicle accident leading cause of death
 Lack adult Judgement
 Major problems: experiment with drugs alcohol Peer pressure
 List educational topics and ideas for implementation of safety interventions
Adult
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May be exposed to injury in the workplace
Lifestyle choices impact health
Some decline in strength and stamina; others maintain fitness
Identify stress relieving interventions that would replace negative coping mechanisms in this
group life span
Older Adult
 Experience many age related changes:
 Slowed reflex responses
 losses sensory: Presbyopia Presbycusis
 Risk: falls, burns car accidents and other injuries
 List interventions contribute to the older adult’s ability to remain safe in the home environment
Case Study
Alvin is a 79 year old man who was just transferred from a long term care facility to your unit. He was
admitted for Dehydration and pneumonia. The night nurse reports that he rested well during the night
and he was alert and oriented x4. When you enter his room, He is confused and does not know where
he is. He becomes increasingly combative and attempts to get out of bed.
1. What actions should you take to keep this client safe?
 Ask for 1:1
 Asses the patient
 Make sure bed is lowered
2. What factors do you think contributed to this sudden change in the client status
 dehydration, pneumonia, his age, oxygen saturation
3. List 3 therapeutic techniques that may be used to decrease Alvin’s agitation
 Reorient the patient
 Communication
 Showing empathy
 Ask family members to talk to him
Knowledge Check
In meeting the safety needs of the adolescent client, it would be most important for the nurse to focus
their teaching on:
A. Smoking cessation
B. Sports injuries
C. Alcohol abuse
D. Driver’s education
Answer:
D
Rationale: The leading cause of death for adolescents is motor vehicle accidents
Individual Factors Affecting Safety
 Lifestyle
 Cognition
 Sensor perceptual status (hearing, vision problems)
 Ability to communicate (culture, language barrier, ability to speak)
 Mobility status
 Physical and emotional health (depression, anxiety)
 Safety awareness
Safety Hazards in the Home
 Poisoning (call poison control, call 911)
 Carbon Monoxide Exposure
 Scald and Burn incidence
 Firearm Injuries (lock firearms at home)
 House fires
 Suffocation Asphyxiation(co-sleeping with babies, leaving kids in a hot car)
 Children up to age 4 years are especially at risk for drowning
Safety Hazards in the Community
 Motor Vehicle Accidents
 Failure to use seat belts and proper child car seats are the major contributing factor
 Driver distraction (e.g. use of cellphones, eating, adjusting radio)
 Pollution
 Air pollution (e.g. car emissions, asbestos, allergens, smoke)
 Water contamination
 Noise (e.g. construction sites, major roadways and trains)
 Soil (e.g. pesticides, toxic waster, medical waste)
 Weather Hazards
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More than 1000 people die each year due to weather hazards in US
Safety Hazards in the Healthcare Facility
 Never events
 Also know as serious reportable events
 Healthcare acquired complications that can cause serious injury or death and should
never happen in hospital (e.g. surgical errors, falls, siderails injury, transfusion errors)
 Three characteristics:
 Clearly identifiable and measurable
 Serious
 Usually prevented
 Root cause analysis
 To prevent “never events” to happen again
 Three questions:
 What happened?
 Why did it happen?
 What can be done to prevent it from happening again?
 Incident reports (belongs to facility for quality improvement)
 Culture of safety
 Team empowerment, communication, transparency, accountability
 Nurses practice in an environment where all staff work together to create a safe unit,
disclose errors without fear, and address any safety concerns
 Equipment related accidents
 Equipment malfunction or improper use
 Material safety data sheets
 Alarm safety
 Alarm fatigue occurs when nurses become overwhelmed by the number of alarm signals
and begin to ignore, delay response to alarms, or even deactivate them
 Joint Commission named alarm desensitization a National Patient Safety Goal
 Fire and Electrical Hazards
 Restraints (never for nurse convenience)
 Falls
 Prevention: Fall risk assessment, environmental safety, clean dry floors, client
education
 Alarm fatigue
 Equipment-related accidents
 Fires/electrical hazards
 Standard precautions
 Mechanical lift use
NCLEX Application
A nurse is ambulating a client in the hall way several rooms away from the client’s room. During the
walk the client states “I feel so dizzy and weak; I don’t think I will make it back to the room” What
actions should be implemented at this time?
A. Return the client quickly to bed
B. Lower the client to the floor gently
C. Walk toward the client’s room slowly
D. Call another nurse to assist with client immediately
Answer
B.
Rationale:
 Lowering the client to the floor gently allows the nurse to prevent the client’s head from hitting
the floor. It controls the client’s movement toward the floor preventing injury to the client and
the nurse.
 Calling another nurse is admirable but there may not be enough time for the nurse to arrive to
be of assistance
NCLEX Application
What Actions are essential when maintaining standard precautions? Select All that Apply
A. putting on a gown when changing soiled linens
B. Disposing of soiled tissue in a water resistant bag
C. Wearing gloves during contact with the client’s body
D. Donning a mask with eye shields when entering the client’s room
E. Washing hands with antimicrobial gel hands are visibly soiled
Answers
B,C
Rationale:
 A gown is not necessary to maintain standard precautions when changing soiled linen. However,
the nurse should wear gloves and hold the linen away from the uniform to prevent
contamination
 Soiled tissues need to be contained in impervious bag.
Skin Integrity & Wound Care
Key Concepts:
Integumentary system consists of:
 Skin, Hair nails sweat glands and subcutaneous tissue below the skin.
 One of the largest organs of the body
Functions:
 Protection of internal organs
 Unique Identification: pigmentation
 Assist in thermoregulation, metabolism of nutrients metabolic waste product and sensation
Skin Integrity- all layers of the skin must be intact
Wound- disruption in skin integrity
Structure of the Skin
1. Epidermis- Outer most Portion of skin composed of 4-5 layers
 Stratum Corneum
 serves as a barrier (outermost; composed of dead cells)
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Restricts water loss
Prevents entry of fluids, pathogens, and chemicals
 Stratum germinativum or basale: (innermost) produces new skin cells
 Keratinocytes - protein containing cells giving skin strength and elasticity
 Melanocytes - contains melanin, produces skin color, protect UV light
 Langerhans cells: responsible for phagocytosis
2. Dermis - Below the epidermis gives elasticity and strength to skin
3. Subcutaneous Tissue - Composed mainly of adipose tissue: provides insulation protection and
reserve of calories
Factors Affecting skin Integrity
 Age
Older adult skin
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 Less elastic, drier
 reduced collagen
 areas of hyperpigmentation
 more prone to injury and prolong wound healing
 Mobility status
 Increased pressure, shearing, and friction can lead to breakdown
 Nutrition/hydration status
 Protein: Maintain the skin, repair minor defects, and preserve intravascular volume
 When protein declines: skin injury slow to heal, fluid leaks (edema) making skin
prone to breakdown
 Calorie intake
 Vitamin C, zinc, copper: formation and maintenance of collagen
 Deficiencies on these delay wound healing
 Hydration
 Dehydration = poor turgor greater than 3 sec
 Dehydration and overhydration (result in edema) make skin prone to injury
 Impaired circulation
 Negatively affects tissue metabolism preventing or delaying wound healing
 One of the main cause of "chronic" wound
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Medications
 Meds that causes itching, rashes, hair loss, photosensitivity, or pigmentation can result
in changes in skin integrity and delay healing
 Certain drugs delay wound healing (e.g.) NSAIDS, Steroids, cancer drugs
Moisture
 Leads to maceration (softening of the skin)
 Incontinence and fever most common sources of moisture
 "feces" contain digestive enzyme and microorganism that can cause denuding
(excoriation) of skin layers
Fever
 Leads to sweating encouraging moisture
 Increases metabolic rate
Infection
 Means microorganism is causing harm by releasing toxins, invading body tissues, and
increasing its metabolic demand
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Impedes healing
 Infection in the wound if not stop can gain entry to systemic circulation (sepsis)
 All chronic wounds considered contaminated
Lifestyle
 Tanning, bathing, piercings, tattoos
 Regular exercise helps maintain skin integrity
NCLEX Application
A nurse is caring for several clients. Which client is at greatest risk for skin break down?
A. Client who is dehydrated
B. Client who has diaphoresis
C. Client who is incontinent of feces
D. Client who has difficulty moving up in bed
Answer
C.
Rationale: Feces contain fluid and digestive Enzymes that injure skin if not removed immediately. Urine
and feces can cause loss of superficial layers of skin.
Types of Wounds
 Based on the skin integrity of the wound
1. Closed wounds - no breaks on the skin (e.g. contusion or tissue swelling)
2. Open Wounds - break in the skin or mucous membrane (e.g. abrasions, lacerations, puncture,
surgical incisions)
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Length of time for healing
1. Acute wounds
 Short duration
 No complication while going through phases of wound healing (inflammation,
proliferation, maturation)
2. Chronic wounds
 Exceeded expected length of recovery due to infection, continued trauma, ischemia, or
edema
 Unless treated may linger for months or years
 E.g. pressure injury, arterial, venous, and diabetic ulcers
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Level of contamination
1. Clean wounds
 uninfected wounds with minimal inflammation
 Minimal or little risk for infection
 Do not involve wounds in respiratory, GI, genitourinary tracts
2. Clean-contaminated wounds
 Surgical incisions that enter respiratory, GI, genitourinary tracts
 Increase risks for infection; but no obvious sign of infection
3. Contaminated wounds
 Open, traumatic wounds or surgical incisions in which a major break of asepsis occurred.
 Risk for infection high
4. Infected wounds
 Bacteria in the wound greater than 100,000 per gram of tissue
 Signs for infected wound erythema (redness), swelling, foul odor, severe or increasing
pain, large amount of drainage, warmth on the surrounding tissue
 Presence of beta-hemolytic streptococci in any number considered infected
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Depth and location of the wound
1. Superficial wounds - only epidermal layer of the skin usually as a result of friction, shearing,
burning
2. Partial-thickness wounds - extends through epidermis but not dermis
3. Full-thickness wounds - extends to subcutaneous and beyond
 Word "penetrating" sometimes added to signify breach to internal organs
Wound Healing Process / Types of Healing
 Regeneration
 In epidermal wounds (e.g. partial-thickness wounds)
 No scar
 New skin indistinguishable from intact skin
 Primary intention
 Occurs when a wound involves minimal or no tissue loss and edges approximated
(closed) well
 Clean surgical incision heals this way
 Minimal scarring (scar only 80% stronger than original)
 Secondary intention
 Happens when wound has extensive tissue loss preventing edges from approximating
 Also from wounds not allowed to close (e.g. due to infection)
 Heals from inner layer to surface by filling in granulation tissue - connective tissue with
rich blood supply)
 These wounds heal more slowly and have an increased risk of infection
 Tertiary intention
 Granulating tissue brought together
 Delayed closure of wound edges
 These require sterile technique when cleaning (e.g. suture wounds)
 Maybe used for clean-contaminated or contaminated wounds
Phases of Wound Healing
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Inflammatory Phase -Cleansing
 Lasts 1-5 days
 Involves two major processes:
a. Hemostasis - cessation of bleeding through area vessels constricting, platelets
aggregating, and forming of platelet plug (clotting mechanism)
b. Inflammation - characterized by edema, erythema, pain, temperature elevation,
migration of WBC
 Macrophages engulfs bacteria and later forms a scab
Proliferative phase: Granulation
 Lasts 5-21 days
 Formation of collagen and epithelial cells
 Formation of granulation tissue that easily bleeds until epithelial cells close wound
completely
Maturation phase: epithelization Formation of scar tissue
 Also known as remodeling
 Begins after the 3rd week of injury and continues even after the wound is closed
 Collagen fibers are broken down and remodeled
Wound Closures (for primary and tertiary intention)
 Adhesive strips
 Sutures (stiches)
 Surgical staples
 Made of titanium
 Lower risk for infection
 Wounds on the hands, feet, neck, or face should not be stapled
 Surgical glue
 For cleans, low tension wounds (e.g. skin tears)
Wound Drainage
Exudate - drainage that oozes from a wound or cavity
 Serous exudate
 Straw colored fluid (serum) and watery in consistency
 Typically in clean wounds
 Sanguineous
 Bloody drainage indicating damage to capillaries
 Often seen in deep wounds or wounds in highly vascular areas
 Serosanguineous
 Mix of bloody and straw-colored fluid
 Seen in new wounds
 Purulent
 Yellow, contains pus (fluid with WBC, bacteria, cellular debris))
 Usually in infected wounds from pyogenic bacteria
 Nurse needs to follow up
 Purosanguineous exudate
 Contains blood and pus
 Indicates ruptured smalls vessels in the wound
Wound Complications
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Hemorrhage
 Profuse or rapid loss of blood
 Risk of hemorrhage greatest in the first 24 to 48 hours after surgery or injury
Infection
 Suspect infection if a wound fails to heal
Dehiscence
 Rupture (separation) of one or more layers of a wound (muscle intact)
 Usually occur in the inflammatory phase of healing
 Nursing intervention
 Bedrest with head of the bed elevated 20 degree and knees flexed
 Applying binder to prevent evisceration
 Notify provider immediately
Evisceration
 Total separation of the layers of a wound with internal viscera (organs) protruding
through the incision (muscle separated)
 This is a surgical emergency
 Nursing intervention
 Immediately cover wound with sterile towels or dressing soak in sterile saline
(prevent organs from drying out and contaminated)
 Patient stay in bed with knees bent
 DO NOT Put a binder
 Notify surgeon immediately
Fistula formation
 Abnormal passage connecting two body cavities or a cavity and the skin
 Result from infection or debris left in the wound
 Most common sites in GI and genitourinary tracts
Wound Assessment
 Focused skin assessment
 Braden scale: Sensory perception, moisture, activity, mobility, nutrition, and friction or
shear
 Total score less than 18 = risk
 Wound assessment
 Location
 Describe location in anatomical terms
 Location influences the rate of healing
 Location affects movement
 Location can you clues to the wound etiology
 Size
 Measure length and width in centimeters
 Undermining or tunneling
 Asses wound edges
 Appearance
 Type of wound
 If the wound is sutured, examine the closure
 The color of the wound
 Condition of the wound bed
 Examine for necrosis, slough, eschar
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 The skin surrounding the wound
Drainage
 Presence of drainage or exudate
 Quantity of drainage (weighing dressing before applied and compare after)
 If drain is present, measure the amount
 odor
Redness
Swelling
Pain
 Any wound causing severe pain requires a comprehensive evaluation
Nutritional status
Wound Stages
 Stage 1 Localized areas of red intact skin
 Non blanchable- does not become pale under applied light pressure
 Stage 2 Wound is open but very superficial
 Involves partial loss of dermis
 Stage 3 Full thickness skin loss
 Adipose is visible (yellowish)
 Damage or necrosis of subcutaneous tissue
 Stage 4 Bone and tendon present in the wound bed
Wound Interventions
 Turn and reposition immobile clients every 2 hours or more
 Maintain good nutrition Diet rich in Vitamin C, and protein
 Prevent incontinence
 Weekly measurements to document progress or regression
What Assessments can I delegate?
 Inspection of the skin for evidence of skin breakdown (UAP)
 Turning and position changes (UAP)