Fundamentals 4 - Ch 19

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Gurnick Academy Of Medical Arts *

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Chemistry

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May 2, 2024

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docx

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Ch 19 (Ch 37 in ATI) Hygiene, Personal Care, Skin Care, and Prevention of Pressure Injuries Integumentary system is skin, hair, nails Skin is the largest organ in the body Skin layers (dermis) - strong and elastic. Contains blood vessels, nerves, hair follicles, fibroblast, glands. Hair and nails are dead keratin with no blood supply or nerve endings Mucous membranes line cavities and passageways in the body They protect against bacterial invasion. Found in the mouth, respiratory tract, GI tract, and urinary tract. Skin is for protection (against bacteria and injury), sensation (touch/pain/heat/cold), and temperature regulation (constricting/dilating and activating sweat glands). Sweat glands help maintain homeostasis of fluids/electrolytes and secrete nitrogenous waste Loss of elastic fibers causes skin to wrinkle. Skin becomes thinner, fragile, slower to heal with age. Hygiene is proper care of skin, hair, teeth, nails. Protects you from disease/infection. Hygiene influenced by: Socioeconomics, economics, knowledge, ability, preferences, culture. Skin Assessment: Bath. Check condition of patient’s skin Overall physical appearance Emotional status Mental status Learning needs Pressure injuries form from local interference with circulation Skin blanches or becomes pale under pressure. It should become darker as blood supply returns Risk factors: immobility , incontinence, diaphoresis, poor nutrition, lowered mental awareness, age, edema. Always use a protective barrier (cream) for someone incontinent. Higher calorie, high protein diet reduces the risk of a pressure injury. Skin assessment for pressure injury risk on admission. Braden Scale predicts risk (points for factors i.e. age)
Stages of Pressure Injuries - Suspected deep tissue injury - Localized discolored intact skin Stage 1 - area of reddened skin does not blanch when touched (with dark skin look for warmth, edema, or induration(hardening)) Stage 2 - partial-thickness skin loss. Abrasion, blister, shallow crater. Stage 3 - full-thickness skin loss - deep crater. May extend into fascia. subcutaneous tissue damaged or necrotic Stage 4 - Full thickness skin loss - extensive tissue necrosis. Damage to muscle or supporting structures. May appear dry/black Preventing Pressure Injuries - ● Change pt position every 2 hours ● Keep heels of immobile patients off the bed (floating the heel) ● Avoid positioning directly on the trochanter see photo of trochanter → ● Use trapeze or lift sheet to change position ● Use pressure-reducing devices (foam pads, mattresses) ● Shift weight at least once per hour, preferably every 15 minutes ● Restore circulation by rubbing around (not on) a reddened area (except on a bony prominence) ● Wash and dry incontinent patients promptly ● Adequate nutrition and hydration ● Avoid skin injury from casts, braces Nurses can diagnose with: ● Acute pain ● Chronic low self-esteem ● Chronic pain ● Dressing self-care deficit ● Imbalanced nutrition: less than body requirements ● Impaired skin integrity ● Impaired physical mobility ● Ineffective peripheral tissue perfusion ● Risk for impaired skin integrity
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