Ch. 19

first line of defense against bacteria and other organisms; protects against thermal, chemical and mechancial injury

contains sensory organs for touch, pain and heat and cold

regulates temperture by constricting or dilating blood vessels and activating or inactivating sweat glands

Make sure their getting an adequate amount of FLUID

sweat glands help maintain the homestasis of fluids and electroytes

sweat glands serve as organs of excretion secretingn nitrogenous waste

sweat glands in axillae and external genitalias secrete fatty acids and protiens

• sebrum lubricates skin n hair
• sebum keeps structures pilate and elastic
• sebrum decreases heat loss
• sebum decreases bacterical growth

1. loss of elastic fibers cause skin to wrinkle and sag

2. skin becomes thinner, fragile and slower to heal

3. Decrease sebacous activity leaves skin dry and itchy, temperture control is altered by decrease sebacous gland activity and thinner

4. Hair becomes thinner, grows more slowly and loses its color from loss of melanocytes

the practice of cleanliness that is conductive to health

• socioeconomic background
• economic status
• knowleadge level
• abitity to perform self-care

CULTURAL DIFFERENCES

the skin

physical apprerance

emotional and mental status

learning needs

Presure ulcers

Ulcers are form from local interfernce with circulation usually in one area

the skin blanches and becomes pale

If interference (pressure) is removed, skin will become darker as blood supply returns [reactive hyperemia]

• 1. Confinement to bed or chair
• 2. Inability to move
• 3. Loss of bowel or bladder control
• 4. Poor nutrition
• 5. Lowered mental status
• 6. Dehydration
• 7. Obesity
• 8. Excessive diaphoresis
• 9. Extreme age
• 10. Edema

1. Confinement to bed or chair

2. Inability to move

3. Loss of bowel or bladder control

4. Poor nutrition

5. Lowered mental status

loss of muscle control causes the skin to sag, if skin is not clean and dry there will be a yeast infection

move the skin and wash really well and dry well to prevent infection

Perform on admission, use

• braden scale- predicting pressure sore risk
• (sensory perception, moisture, activity, mobility, nutrition, friction n shear)

Reassess often every 24 hours

Check for bony prominences and reactive hyperemia

DOCUMENT COMPLETELY

reassess patients that cant move or incontinent or confined to bed

also patients that are (sitting, laying on back and side)

elbows, heals, scapula, knee, hips, ankles

Area of reddened skin that does not blanch when touched. Area still intact

In people with darker skin, discoloration of the skin, warmth, edema or induration (area feels hard)

Partial thickness skin loss

involving epidermis and dermis. It may look like an abrasion, blister, or shallow crater

surrounding skin may feel warmer

Full-thickness skin loss

looks like a deep crater, may extend into the fascia subcutaneous tissue damaged or necrotic

Bacterial infection of the ulcer id common and causes drainage from ulcer

Full-thickness skin loss

• Extensive tissue necrosis or damage to muscle or supporting structures may
• appear dry and black

there is no circulation to it, cant have a pressure heal if there is no circulation

surgerons can cut away to healthy tissue (bleeding)

these ulcers cant heal any other way but from the inside out

the ulcer may appear dry and black with a buildup of tough, necrotic tissue

(wet and oozing)

loss of full thickness of tissue. The base of the ulcer is covered by eschar (tan, brown or black

or base of ulcer contains slough (yellow, tan, gray, green, or brown)

to get rid of dead tissue (debris) taking off dead

document what you see

• 1. Depth
• 2. Size
• 3. Color
• 4. Warmth
• 5. Drainage
• 6. Location

• 1. assess skin carefully and frequently
• 2. change patient postion every 2 hrs
• 3. keep heals of immobile patients off the bed

4. Avoid positioning the patient directly on the trochanter (hip)

5. Use a trapeze or lift shet to change the patient's posisition

6. Use pressure reducing devices such as (foam pads or mattresses)

• 7. Use pressure reducing devices for patients in a wheelchair
• (shift weight at least once an hour, preferably 15 minutes)

8. Restore circulation to areas by rubbing AROUND a reddened area

9. DO NOT massage reddened skin or over a bony prominece

10. Wash and dry incontinent patients promptly

11. Avoid mechanical injury from cast, braces, etc

12. Avoid skin injury caused by friction and shear

13. Provide adequate nutriton and hydration

DOCUMENT THAT YOU TURNED PATIENT

every 1-2 hours offer a drink for patients that cannot eat or feed themselves

It is the NURSE responsible to make sure their hydrated 8oz

Excellent Nursing Care

Lift patients up, Hydrated them, good nutrition

• If patient has a skin tear the dont remove it, they lay it back down & put a dressing over it. When they remove the dressing the skin will come off

Excellent nursing care is the main factor in prevention of pressure ulcers and is a team effort

Inital care include:

• 1. Debridement
• 2. Wound cleansing
• 3. Application of dressing

the patient, family, and health care providers (team approach) the patient should be encouraged to be acitve participant. Educate the patient on how pressure ulcers are develop and how to treat them.

Initial care may require antibiotic therapy

• Self care deficit
• Impaired physical mobitity
• Impaired skin integrity
• Pain
• Imbalanced nutrition

Try to get most patients up before breakfast and fully dressed.

• Offer bedpan or urinal and provide help to bathroom
• 2. Wash hands and face
• 3. Clean and clear the over the bed table
• 4. Provide oral care
• 5. Prepare for tests or surgery (shaves)

Usually occurs after breakfast and is the main hygiene

• 1. Offer bedpan or urinal
• 2. Provide oral care
• 3. Straighten the unit
• 4. Nail care
• 5. Give back rub
• 6. Shave and provide hair caere
• 7. Dress

• 1. Offer bedpan or urinal
• 2. Provide care after any dianositic test as needed
• 3. Provide oral care

• 1. Offer bedpan or urinal
• 2. Wash hands and face
• 3. Provide oral care
• 4. Change gown if needed
• 5. Give back rub
• 6. Help adjust patient position in bed
• 7. Straigten the unit
• 8. Fresh water

Linens are straighten and changed as needed throughtout the day

• 1. Promote Comfort
• 2. Cleanse the skin
• 3. Stimulate circulation
• 4. Remove waste products

Patient should be covered to prevent chills

Water temperture should be approximately 105 degrees

• 1. The patients skin integrity wil be maintained
• 2. The patients hair is clean and neatly styled
• 3. The patients mouth is intact and free of odor

The most common done in bed, tub or shower offer patient use of toilet before setting up for bath

May need assistive devices such as chair or stool in shower or tub

Once patient is in the tub add warmer water as desired. A call bell should be within reach

• check on patient every 5 mins
• and it shouldnt exceed 15-20 mins

Whirlpool bath- done in bathtub or special whirlpool tub that has a device that agitates the water

they cleanse, stimulate peripheral cirulation and provide comfort

Oatmeal and starches are added for patients with dermatitis

Sitz baths used to apply moist heat and clean the perineal or anal area

promote healing, relieves pain and discomfort

commonly used after birth or vaginal or rectal surgery

• 1. Communicates caring
• 2. Fosters trust in the nurse patient relationship
• 3. Provides an opportunity for skin assess
• 4. Stimulates circulation of blood to the area
• 5. Reduces tension and promotes relaxtion

• routine care is usually preformed in the morning
• consists of bathing (full or partial bed bath), perinela care, oral care, hair care and shaving

Mouth care helps to remove food particles and secretions which prevents (halitosis) feellings of uncleanliness and dental caries

Oral care may need to be performed several times a day

Performed on unconscious patients every 8 hours (sitting on their side)

Suctioning is at the bedside because it removes any secretion from the mouth to prevent it from getting in their lungs and causing patient to asparate.

• 1. If patient is not awake dont put dentures in
• 2. Prior to putting dentures in mouth need to be clean
• 3. Clean dentures before and after bed

PUT WASHCLOTH down in sink before cleaning the dentures to prevent breakage

4. Dentures should be kept in a label denture container cool water or normal saline

5. Brush from gumline to the edge of teeth

6. Raise head of bed 45 degrees

Brushing hair stimulates circulation which promotess hair growth, prevent hair loss, distribute oil along hair shafts and bring nutrients to the roots

Should be brushed from scalp to end to help with oils

Use alcohol or water to dantangle hair

YOU MUST HAVE A CONSTANT TO CUT HAIR

SHAVING

Know what medication their on because some meds cause patient to bleed heavy like anticoagulant (blood thinner) COMUDAN, ASPIRIN

Patients on blood thinning meds can not use a disposable razor you must use an electrical razor

If patient is taking an aspirin once a day use a electrical razor because blood is thin

Shave in the direction of hair growth, gentle strokes, before shaving take warm washcloth and sofen the skin and hold skin

• stroke up under the chin and down on the cheecks
• 30-45 degree angle

rinse after every 2-3 strokes

Nail care may need to be provided with patients that are unconscious, blind, confused unsteady or in cast traction.

Diabietics patients should not have theri toenails cut without a doctors order

Use an orangewood stick to clean under nails and push back cuticles

Glasses store glasses in case, clean lenses with warm water and a soft cloth to wipe dry, Do NOT use a paper towel

Contact lenses to remove a hard lens wash hands and remove it by lifting up eyelid

Hearing aids- 1. body worn, 2. behind the ear, 3. attached to the eyeglases 4. in the ear 5. in ear cancal

store hearing aids in case and clean them with soap and water dont submerge them in water