UNIT VI: SKIN MANAGEMENT
• FUNDAMENTAL OF NURSING-I
• BSN (GENERIC) SEMESTER 1ST
ASIAN INSTITUTE NURSING HEALTH
SCIENCES
FACULTY BHAGCHAND LAWO
• NURSING LECTURER (AINHS) 1
SKIN MANAGEMENT
2
TOPIC : SKIN MANAGEMENT
OBJECTIVES:
•AT THE END OF THE SESSION LEARNERS WILL
BE ABLE TO:
•1. DEFINE DECUBETIC ULCER (BED SORE)
•2. LIST THE CAUSES OF DECUBETIC ULCER
•3. APPLY NURSING INTERVENTIONS TO
PREVENT DECUBETIC ULCER.
• 4. IDENTITY RISK FACTORS OF BEDSORES
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DECUBETIC ULCER (BED SORE)
• DEFINITION
• PRESSURE ULCERS WERE PREVIOUSLY CALLED
DECUBITUS ULCERS, PRESSURE SORES, OR BED
SORES. A PRESSURE ULCER IS ANY LESION
CAUSED BY UNRELIEVED PRESSURE ( A
COMPRESSING DOWNWARD FORCE ON A BODY
AREA ) THAT RESULTS IN DAMAGE TO UNDERLINE
TISSUES.
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DECUBETIC ULCER (BED SORE)
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ETIOLOGY/CAUSES OF PRESSURE
ULCERS
• PRESSURE ULCERS ARE DUE TO LOCALIZED
ISCHEMIA, A DEFICIENCY IN THE BLOOD
SUPPLY TO THE TISSUE. THE TISSUE IS
COMPRESSED BETWEEN TO SURFACES,
USUALLY THE SURFACE OF THE BED AND
THE BONY SKELETON, WITH GREATER
THAN 32MMHG PRESSURE.
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ETIOLOGY/CAUSES OF PRESSURE
ULCERS CONT’D…..
• WHEN BLOOD CANNOT REACH THE TISSUE,
THE CELLS ARE DEPRIVED OF OXYGEN AND
NUTRIENTS, THE WASTE PRODUCTS OF
METABOLISM ACCUMULATE IN THE CELLS
AND THE TISSUE CONSEQUENTLY DIES.
PROLONGED UNRELIEVED PRESSURE ALSO
DAMAGES THE SMALL BLOOD VESSELS.
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COMMON SITES OF
PRESSURE ULCER ON
SITES
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COMMON SITES OF
PRESSURE ULCER ON SITES
RISK FACTORS
• [Link] AND SHEARING:
TWO OTHER WORDS FREQUENTLY ACT IN
CONJUNCTION WITH PRESSURE TO PRODUCE
PRESSURE ULCER FRICTION AND SHEARING FORCE.
FRICTION IS A FORCE ACTING PARALLEL TO
• FRICTION:
THE SKIN SURFACE.
E.G.: SHEETS RUBBING AGAINST SKIN CREATES
FRICTION.
A COMBINATION OF FORCE AND
• SHEARING FORCE: IS
PRESSURE. IT OCCURS WHEN CLIENT USUALLY
ASSUMES A FOWLER’S POSITION IN BED 11
• 2 IMMOBILITY MEANS THE INABILITY TO MOVE FREELY
OR CHANGE BODY POSITIONS WITHOUT ASSISTANCE. IT CAN BE
TEMPORARY, LONG-TERM, OR PERMANENT, AND IT IS A MAJOR
RISK FACTOR FOR DEVELOPING PRESSURE ULCERS (BED SORES
• CAUSES OF IMMOBILITY:
• PARALYSIS (E.G., SPINAL CORD INJURY)
• COMA OR UNCONSCIOUSNESS
• SEDATION OR ANESTHESIA
• SEVERE ILLNESS (E.G., STROKE, ADVANCED CANCER)
• POST-OPERATIVE RECOVERY
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• HOW IMMOBILITY LEADS TO PRESSURE ULCERS:
• THE PATIENT STAYS IN ONE POSITION TOO LONG.
• CONTINUOUS PRESSURE OVER BONY AREAS.
• BLOOD FLOW IS REDUCED LOCALIZED ISCHEMIA.
• TISSUE DAMAGE OCCURS → ULCER FORMS
• HIGH-RISK AREAS IN IMMOBILE PATIENTS:
• SACRUM
• HEELS
• HIPS
• ELBOWS
• SHOULDER BLADES
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• BACK OF THE HEAD
• 3. INADEQUATE NUTRITION.
• PROLONGED INADEQUATE NUTRITION
CAUSES WEIGHT LOSS, MUSCLE ATROPHY,
AND THE LOSS OF SUBCUTANEOUS TISSUE.
THESE THREE REDUCE THE AMOUNT OF
PADDING BETWEEN THE SKIN AND THE
BONES, THUS INCREASING THE RISK OF
PRESSURE ULCER DEVELOPMENT.
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• 4. FECAL AND URINARY
INCONTINENCE
• MOISTURE FROM INCONTINENCE
PROMOTES SKIN MACERATION (TISSUE
SOFTENED BY PROLONGED WETTING OR
SOAKING) AND MAKES THE EPIDERMIS
MORE EASILY ERODED AND SUSCEPTIBLE
TO INJURY.
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• 5. DECREASED MENTAL STATUS
• INDIVIDUALS WITH A REDUCED LEVEL OF
AWARENESS E.G. THOSE WHO ARE
UNCONSCIOUS ,HEAVILY SEDATED OR
HAVE DEMENTIA ARE AT RISK OF
PRESSURE ULCER. BECAUSE THEY ARE
LESS ABLE TO RECOGNIZE AND RESPOND
TO PAIN ASSOCIATED WITH PROLONGED
PRESSURE.
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[Link] SENSATION
PARALYSIS, STROKE OR OTHER NEUROLOGIC
DISEASE MAY CAUSE LOSS OF SENSATION IN A
BODY AREA. LOSS OF SENSATION REDUCES A
PERSONS ABILITY TO RESPOND TO TRAUMA, TO
INJURIOUS HEAT AND COLD, SENSORY LOSS
ALSO IMPAIRS THE BODY’S ABILITY TO
RECOGNIZE AND PROVIDE HEALING MECHANISM
FOR A WOUND.
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7. EXCESSIVE BODY HEAT
BODY HEAT IS ANOTHER FACTOR IN THE
DEVELOPMENT OF PRESSURE ULCER. AN
ELEVATED BODY TEMPERATURE INCREASE
THE METABOLIC RATE. THIS INCREASING THE
CELLS NEED FOR OXYGEN SEVERE
INFECTION WITH ACCOMPANYING ELEVATED
BODY TEMPERATURES MAY AFFECT THE
BODY’S ABILITY TO DEAL WITH THE EFFECTS
OF TISSUE COMPRESSION
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8. ADVANCED AGE
THE AGING PROCESS BRINGS ABOUT SEVERAL
CHANGE IN THE SKIN AND IT IS SUPPORTING
STRUCTURE. THESE CHANGES INCLUDE THE
FOLLOWING:
•LOSS OF LEAN BODY MASS
•GENERALIZED THINNING OF EPIDERMIS
•DECREASED STRENGTH AND ELASTICITY OF THE
SKIN DUE TO CHANGES IN THE COLLAGENS FIBERS
OF THE DERMIS.
•INCREASED DRYNESS DUE TO A DECREASES IN
THE AMOUNT OF OIL PRODUCED BY THE
SEBACEOUS GLAND. 19
9. CHRONIC MEDICAL CONDITION
CERTAIN CHRONIC CONDITIONS SUCH AS
DIABETES AND CARDIOVASCULAR DISEASE ARE
RISK FACTORS FOR SKIN BREAKDOWN AND
DELAYED HEALING. THESE CONDITIONS
COMPROMISE OXYGEN DELIVERY TO TISSUES BY
POOR PERFUSION AND
THUS CAUSE POOR AND DELAYED HEALING AND
INCREASE RISK OF PERSONS SORES.
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10. OTHER FACTORS
OTHER FACTORS CONTRIBUTING TO THE
FORMATION OF PRESSURE ULCERS ARE POOR
LIFTING AND TRANSFERRING TECHNIQUES,
INCORRECT POSITIONG, HARD SUPPORT
SURFACES, AND INCORRECT APPLICATION OF
PRESSURE RELIEVING DEVICES.
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CLASSIFICATION OF PRESSURE
ULCERS
Stage I: persistent red, blue, or purple
tones; no open skin areas
Stage II: partial-thickness skin loss;
presents as an abrasion or blister
Stage III: full-thickness skin loss with
damage or necrosis of subcutaneous tissue;
presents as a deep crater
Stage IV: full-thickness skin loss with
extensive destruction, necrosis, or damage
to muscle, bone, other structures 22
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STATISTICS
1) 70% occur in people over 65 age
2) Most common sites are sacrum and
heels
3) Shoulder: heel and ear were the
favorite sites of newly developed
Pressure ulcers.
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NURSING INTERVENTION TO
PREVENT DECUBETIC ULCER
NURSING INTERVENTION FOR MAINTAINING
SKIN INTEGRITY AND WOUNDS CARE
INVOLVE :
•SUPPORTING WOUND HEALING
•PREVENTING PRESSURE ULCER
•TREATING PRESSURE ULCER
•DRESSING AND CLEANING WOUNDS
•APPLYING HEAT AND COLD , AND
• SUPPORTING AND IMMOBILIZING WOUND. 25
SUPPORTING WOUND HEALING
• THE FOUR MAJOR AREAS IN WHICH NURSES CAN HELP
CLIENTS DEVELOP OPTIMAL CONDITIONS FOR WOUND
HEALING ARE:
• [Link] MOIST WOUND HEALING.
• [Link] SUFFICIENT NUTRITION AND
HYDRATION.
• [Link] WOUND INFECTION.
• 4. PROPER POSITIONING
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PREVENTING PRESSURE ULCER
• TO REDUCE THE LIKELIHOOD OF PRESSURE
ULCER DEVELOPMENT IN ALL CLIENTS , THE
NURSES EMPLOYS A VARIETY OF PREVENTING
MEASURES (I.E. SKIN HYGIENE AND PRESSURE
RELIEF DEVICES) TO MAINTAIN THE SKIN
INTEGRITY AND INSTRUCT THE CLIENT,
SUPPORT PEOPLE AND CAREGIVERS IN HOW
TO PREVENT PRESSURE ULCERS.
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PROVIDING NUTRITION
• BECAUSE AN INADEQUATE INTAKE OF CALORIES,
PROTEINS, VITAMINS AND IRON IS BELIEVED TO
BE RISK FACTOR FOR THE PRESSURE ULCER
DEVELOPMENT.
• NUTRITIONAL SUPPLEMENTS SHOULD BE
CONSIDERED FOR NUTRITIONALLY
COMPROMISED CLIENTS.
• THE DIET SHOULD BE SIMILAR TO THAT WHICH
SUPPORT WOUNDS HEALING.
• MONITOR WEIGHT REGULARLY TO HELP ASSESS
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NUTRITIONAL STATUS.
MAINTAINING SKIN HYGIENE
• REASSESS THE SKIN AT LEAST DAILY IN THE
HOSPITAL AND WEEKLY AT HOME.
• WHEN BATHING THE CLIENT, THE NURSE
SHOULD MINIMIZE THE FORCE AND FRICTION
APPLIED TO THE SKIN, AND USING MILD
CLEANSING AGENTS THAT MINIMIZE IRRITATION
AND DRYNESS AND DO NOT DISRUPT THE SKIN
“NATURAL BARRIERS“ AND ALSO AVOID USING
HOT WATER WHICH INCREASES SKIN DRYNESS
AND IRRITATION. 29
CONTINUE………
• NURSES CAN MINIMIZE DRYNESS BY AVOIDING
EXPOSURE TO COLD AND LOW HUMIDITY.
• DRY SKIN BEST TREATING WITH MOISTURIZING
LOTION APPLIED WHILE THE SKIN IS MOIST AFTER
BATHING.
• THE CLIENT SKIN SHOULD BE KEEP CLEAN AND DRY
AND FREE OF IRRITATION AND MACERATION BY
URINE, FECES, SWEAT OR INCOMPLETE DRYING
AFTER A BATH.
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AVOIDING SKIN TRAUMA
• PROVIDING TO THE CLIENT WITH A SMOOTH,
FIRM AND WRINKLE FREE FOUNDATION ON
WHICH TO SITE OR LIE HELPS PREVENT SKIN
TRAUMA.
• TO PREVENT INJURY DUE TO FRICTION AND
SHEARING FORCES, CLIENT MUST BE POSITIONAL,
TRANSFER ED AND TURNED CORRECTLY.
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PROVIDE SUPPORTING DEVICES
• THREE TYPE OF SUPPORTING SURFACES CAN BE
USED TO RELIEVE PRESSURE:
• THE OVERLAY MATTRESS
• A REPLACEMENT MATTERS
• SPECIALTY BEDS REPLACE HOSPITAL BEDS E.G.
HIGH AIR-LOSS BEDS, LOW AIR-LOSS BEDS, AND
KINETIC BEDS THAT PROVIDE KINETIC THERAPY,
PROVIDE CONTINUOUS PASSIVE MOTION.
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TREATING PRESSURE ULCER
• PRESSURE ULCER IS A CHALLENGE FOR NURSES
BECAUSE OF THE NUMBER OF VARIABLE INVOLVED
(E.G. RISK FACTOR, TYPE OF ULCER AND, DEGREES
OF IMPAIRMENT) AND NUMEROUS TREATMENT
MEASURES ADVOCATED.
• EXISTING AND POTENTIAL INFECTION OR THE MOST
SERIOUS COMPLICATIONS OF PRESSURE ULCER.
• NURSES SHOULD FOLLOW THE AGENCY PROTOCOL
AND THE PRIMARY CARE PROVIDER'S ORDER.
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REFRENCE
• 1: KOZIER AND ERB’S, FUNDAMENTAL OF NURSING
EDITION 8TH CHAPTER 36.
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