-
Functions of the skin (Protection)
first line of defense against bacteria and other organisms; protects against thermal, chemical and mechancial injury
-
Sensation (functions of the skin)
contains sensory organs for touch, pain and heat and cold
-
Temperture Regulation
regulates temperture by constricting or dilating blood vessels and activating or inactivating sweat glands
-
If the patient is sweating profusily make sure what......
Make sure their getting an adequate amount of FLUID
-
Excretior and secretion (Functions of the skin)
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
-
Skin changes occuring with AGING
1. loss of elastic fibers cause skin to wrinkle and sag
2. skin becomes thinner, fragile and slower to heal
-
SKIN changes occuring with AGING
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
-
Nursing Process (hygiene)
the practice of cleanliness that is conductive to health
-
List factors effecting hygiene
- socioeconomic background
- economic status
- knowleadge level
- abitity to perform self-care
-
What is the biggest factor effecting hygiene
CULTURAL DIFFERENCES
-
Bath affords opportunity for assessing?
the skin
physical apprerance
emotional and mental status
learning needs
-
If the patient is imobile and cannot move they are at risk for?
Presure ulcers
-
How are ulcers formed?
Ulcers are form from local interfernce with circulation usually in one area
-
Skin and presure ulcers (skin)
the skin blanches and becomes pale
If interference (pressure) is removed, skin will become darker as blood supply returns [reactive hyperemia]
-
Pressure Ulcer Risk Factors
- 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
-
Pressure ulcer MAJOR risk factors
1. Confinement to bed or chair
2. Inability to move
3. Loss of bowel or bladder control
4. Poor nutrition
5. Lowered mental status
-
Obesity
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
-
Assessment (braden scale)
Perform on admission, use
- braden scale- predicting pressure sore risk
- (sensory perception, moisture, activity, mobility, nutrition, friction n shear)
-
Assessment
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)
-
Most common places (Bony Prominences)
elbows, heals, scapula, knee, hips, ankles
-
Stages of Pressure Ulcers
( stage 1)
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)
-
Stages of Pressure Ulcers
(stage 2)
Partial thickness skin loss
involving epidermis and dermis. It may look like an abrasion, blister, or shallow crater
surrounding skin may feel warmer
-
Stages of Pressure Ulcers
(stage 3)
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
-
Stages of Pressure Ulcers
(stage 4)
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
-
Eschar
the ulcer may appear dry and black with a buildup of tough, necrotic tissue
(wet and oozing)
-
Stages of Pressure Ulcers
(unstageable)
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)
-
Whirpool
to get rid of dead tissue (debris) taking off dead
-
Pressure Ulcers
(document)
document what you see
- 1. Depth
- 2. Size
- 3. Color
- 4. Warmth
- 5. Drainage
- 6. Location
-
Preventing Pressure Ulcers
- 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
-
Preventing Pressure Ulcers
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
-
Preventing Pressue Ulcers
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
-
Hydration
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
-
What is the best prevention to treat ulcers?
Excellent Nursing Care
-
Skin tear (prevention)
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
-
Pressure Ulcer Treatment
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
-
Nursing diagnoses
- Self care deficit
- Impaired physical mobitity
- Impaired skin integrity
- Pain
- Imbalanced nutrition
-
Planning Care
(early morning)
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)
-
Planning care
(A.M care)
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
-
Planning care
(Afternoon care)
- 1. Offer bedpan or urinal
- 2. Provide care after any dianositic test as needed
- 3. Provide oral care
-
Planning care
(Hour of sleep 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
-
Bathing (4 purposes)
- 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
-
Nursing goals for hygiene
- 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
-
Types of Bath
(cleansing)
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
-
Types of Baths
(Therapeutic)
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
-
Back rubs
- 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
- 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.
-
Routine Care
(Denture Care)
- 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
-
Hair care
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
-
Routine Care
SHAVING
Know what medication their on because some meds cause patient to bleed heavy like a nticoagulant (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
-
Routine Care
(Toenails)
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
-
Routine Care
(Eye Care and Ear)
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
|
|