Nursing Implementations for Skin Integrity

Nursing Implementations for Skin Integrity

• Patient-centered approach: Nursing interventions are tailored to the specific needs of each patient, considering their mobility, pressure injury risk, and current ulcer stage.

• Focus on prevention: Nursing care aims to prevent ulcers and infections, maintaining skin integrity.

• Systematic Skin Inspection:

  • Conduct a thorough skin inspection at least once daily, paying close attention to bony prominences.
  • This provides valuable data for identifying risk factors and designing interventions.
  • The data collected is then used to evaluate the effectiveness of interventions.

• Routine Skin Care:

  • Systematic, comprehensive, and routine skin care may reduce pressure injury incidence, although the exact mechanism is not fully understood.
  • Clean the skin promptly when soiled and at regular intervals based on the patient's needs and preferences.

• Gentle Skin Cleansing:

  • Avoid using hot water, opt for mild cleansing agents, and perform gentle cleansing with minimal force and friction.
  • This approach minimizes irritation and skin damage.

• Preventing Skin Irritation:

  • Metabolic waste and environmental contaminants accumulate on the skin.
  • Remove these substances frequently to prevent skin irritation.
  • Feces and urine can cause chemical irritation and should be removed as soon as possible.

Nursing Implementations for Skin Integrity

• Nursing implementations depend on the patient's mobility, risk factors for pressure injuries, and existing ulcer staging.
• Nursing care focuses on ulcer and infection prevention.
• Interventions for patients with or at risk for impaired skin integrity include:
  • Daily systematic skin inspection, focusing on bony prominences.
  • Routine, comprehensive skin care may decrease pressure injury incidence, although the exact role is unknown.
  • Skin inspection provides data for nursing interventions to reduce risk and evaluate outcomes.
• Clean the skin when soiled and at regular intervals based on patient need or preference.
  • Use mild cleanser and avoid hot water.
  • Clean gently with minimal force and friction.
• Metabolic wastes and environmental contaminants on the skin can irritate and should be removed frequently.
• Feces and urine cause chemical irritation and should be removed promptly.

Skin Hydration and Environmental Factors

• Ambient air temperature affects skin hydration, especially with low humidity.
• Low humidity and cold exposure increase the risk of skin dryness.
• Well-hydrated skin is more resistant to mechanical trauma.

Skin Dryness and Pressure Injury

• Dry skin is less pliable, increasing the risk of fissuring and cracking of the stratum corneum.
• Avoid massage over bony prominences in at-risk patients, as it may contribute to deep tissue trauma and pressure injury development.

Managing Moisture and Skin Irritation

• Moisture from incontinence, perspiration, or wound drainage can irritate the skin and increase its susceptibility to injury.
• Use absorbent underpads or briefs to manage moisture and provide a quick-drying surface for the skin.
• Change underpads and briefs frequently to prevent moisture buildup.
• Avoid placing plastic directly against the skin, as it can trap moisture and further irritate the skin.

Friction and Shearing Forces

• Friction injuries occur when the skin moves across a rough surface.
• Shear injuries occur when skin remains stationary, but the underlying tissue shifts.
• These injuries can lead to ischemia and tissue damage.

Minimizing Friction and Shear Injuries

• Use proper positioning, transferring, and turning techniques.
• Avoid dragging the patient's skin across bed linens.
• Use positioning devices like pillows and foam wedges to protect bony prominences.

Preventing Skin Injuries in Immobile Patients

• Reposition immobile patients at least every 2 hours, using a systematic schedule.
• This helps prevent pressure injuries and optimize circulation.

Pressure Relief for Immobile Patients

• Use devices to relieve pressure on the heels of immobile patients.
• Raising the heels off the bed is a common method for pressure relief.
• Avoid using doughnut-type devices as they can increase pressure and damage tissue.
• Patients needing prolonged time laying down require pressure reduction devices to prevent pressure injuries.
• Avoid placing patients directly on their trochanter in side-lying position, as this can increase the risk of pressure injury.
• Keep the head of the bed at the lowest elevation possible while considering medical conditions and restrictions.
• Limit the duration of head of bed elevation to decrease pressure injury risk on bony prominences like the sacrum.

Using Assistive Devices for Transfers

• Utilize assistive devices like trapezes or draw sheets when moving patients who can't assist.
• This minimizes shear and friction injuries.

Chair-Bound Patient Positioning

• Utilize pressure-reducing devices for chair-bound patients.
• Consider postural alignment, weight distribution, and pressure relief when positioning.
• Prevent uninterrupted sitting in chairs or wheelchairs.
• Reposition patients hourly.
• Teach patients who can to shift weight every 15 minutes.
• Utilize a written plan for positioning, movement, and device use.

Collaboration for Pressure Injury Care

• Nurses often collaborate with physical therapists in hospitals, rehabilitation centers, and long-term care facilities.
• When caring for home-bound patients, nurses collaborate with primary caregivers.
• Nurses provide education to caregivers on:
  • General information about pressure injuries.
  • Risk factors for pressure injuries.
  • Skin care and pressure injury prevention.
  • Diet and nutrition.

This quiz covers key nursing interventions aimed at maintaining skin integrity in patients. You will learn about patient-centered approaches, systematic skin inspections, and effective routine skin care practices. Understanding these principles is essential for preventing pressure injuries and promoting overall patient health.