Safety & Integumentary Nursing 110 Key Concepts Safety: 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 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 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 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) 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 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 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 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) 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 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 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 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 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 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)
