Pressure Injuries and Nursing Skills Lecture

Promoting Hygiene Lecture Notes

• Learning Objectives: Students will be able to discuss the importance of personal hygiene, demonstrate nursing skills in promoting hygiene, describe signs and symptoms and related care for parasitic infestations (scabies, pediculosis capitis), describe contributing factors and characteristics of pressure injuries, and discuss prevention and management of pressure injuries.

Hair Care

• Pediculosis Capitis (Head Lice): Infestation caused by Pediculus humanus capitis. Found on the scalp and in hairs.
• Lifecycle stages: eggs → nymphs → adults. Nymphs and adults suck blood. Adult louse is greyish white, size of a sesame seed, and moves quickly among hair. Lice eggs (nits) are oval, yellow to white, and easily found. Common sites of infestation include the occiput, ears, and neck.
• Eggs hatch in 7-10 days. Nymphs take 7-13 days to mature into adults.
• Lifespan: ~28-30 days, but they usually die 2 days after falling off the host.

Route of Transmission

• Direct head-to-head contact.
• Sharing articles (e.g., combs) that harbor lice.
• Infested upholstered furniture.

Signs & Symptoms

• Oval particles clinging to the hair.
• Frequent scratching/itching due to allergic reaction to bites (of the lice).
• Haemorrhagic spots on skin where lice have sucked blood.
• Itching skin excoriation in the affected area.
• Fine black powders (louse feces) on the pillow.
• Pale colored materials (cast lice skin) on the pillow.
• Tiny oval shaped white or clear dots (lice eggs) on the scalp.
• Tickling sensation of "something moving in the hair".

Diagnosis

• Dry-combing with a closed-set tooth comb.
• Wet-combing after applying conditioner.
• Direct scalp inspection, parting the hair.
• Magnifying glass inspection of the scalp.
• Small hemorrhagic areas.
• Insect-type bites behind ears or hairline.
• Small dandruff-like particles.

Treatments

• Topical pediculicides: (e.g., malathion 5% solution).
• Decontamination is necessary.

Decontamination

• Wash all clothes and beddings used by the infested client separately in hot water (60°C or above) for at least 20 minutes.
• Disinfect combs in a mixture of bleach and water (1:1 ratio) for 30 minutes
• Seal stuffed toys and other non-washable items in plastic bags for 2 weeks.
• Thoroughly vacuum rugs, mattresses, pillows, and furniture

Skin Care

• Bathing: Removes accumulated oil, perspiration, some bacteria, and odor, while restoring cleanliness and promoting comfort. It also stimulates circulation, increases a sense of well-being, and reduces infection risk.

• Types of Baths:

  • Cleansing bath (43°C-46°C)
  • Complete/self-help bed bath
  • Tub bath/shower
  • Bag bath
  • Towel bath
  • Therapeutic bath
  • Medicated bath

Assessment

• Physical and emotional factors.
• Condition of skin: texture, turgor, temperature, lesions, bruises.
• Presence of pain.
• Range of motion.
• Level of cooperation.
• Other aspects of health: mobility, strength, cognition, vital signs.

Planning

• General considerations: Location, timing, assistance needed, toileting before bathing, protection of casts/IV sites, environment, temperature, and privacy.
• Equipment: Basin with warm water, bath mitt and towels, soap, gloves, apron, bed linen, personal care items (lotion, medication), laundry bag, shaving equipment.

Implementation

• Prepare the bed, position the client, lower bed side rail, assist client to move near you, cover client with bath blanket, and remove client's clothes.
• Make a bath mitt with a washcloth.

Body Areas for Hygiene

• Face, ears and neck, arms and hands, chest and abdomen, Perineal & genitalia area, Back, buttock & anal area, Legs and feet

Precautions

• Inspect for abnormalities.
• Provide relevant health education.
• Perform assisted ROM during bed bath, Clean and dry skin-fold areas carefully (groin, skin under breasts, skin between fingers and toes).
• Dress the injured or immobilized side first.
• Wash clients with deep vein thrombosis or blood clotting disorder without long, firm strokes on lower extremities.

Scabies

• Infestation: by the itch mite Sarcoptes scabiei.
• Burrowing: mites burrow just below the skin's surface.
• Egg Laying: Adult female mites lay 2-3 eggs a day at tunnel's end.
• Egg Development: Eggs take 10-17 days to develop into adult mites.
• Mite lifespan: Mites die within 48-72 hours once away from the body.

Scabies: Route of Transmission

• Skin-to-skin contact in crowded conditions (hospitals, old-age homes, child care centers).
• Sharing clothes, towels, and beddings.
• Easily infected sex partners or household members.
• Incubation period: 2-6 weeks

Scabies: Signs & Symptoms

• Burrows: Greyish-white/pink threadlike lines (0.5-1 cm long), found between fingers/on palm/sides of wrist.
• Intense itching: Worsens at night.
• Papules: Small elevated reddish papules, sometimes with tiny vesicles on top, seen on skin surface.
• Common sites: Webs between fingers, nipples, backs of elbows, wrists, sides and backs of feet, knees, around waist, umbilicus, genital area, axillary folds, buttocks.

Scabies: Diagnosis

• Examine burrows/rash.
• Ink test: Apply ink on an itchy spot; wiped with alcohol pad. Ink remaining in burrows is shown as dark lines.
• Microscopic examination of skin scraping: Identify mites, eggs, or fecal pallets.

Scabies: Treatments

• Classic scabies: Permethrin 5% cream, Crotamiton 10% lotion/cream, sulfur ointment, Lindane 1% lotion, ivermectin (oral drug).
• Norwegian scabies: Ivermectin (oral drug), Permethrin 5% cream, Benzyl benzoate 25% ointment, Keratolytic cream.

Topical Scabicides: Precautions

• Implement contact precautions.
• Apply medication from neck to toes (exclude lips and eyelids).
• Pay attention to skin folds, webs between fingers and toes, and nails.
• Reapply if washed off (during treatment).
• Leave on for the recommended period, then take a bath to rinse off the medication.

Permethrin 5% Cream

• Approved for scabies treatment in those at least 2 months old.
• Kills both mites and eggs.
• Two (or more) applications—one week apart—may be necessary to eliminate all mites.

Prevention Measures (infection control)

• Isolate infested patients before treatment.
• Limit the number of visitors.
• Visitors must wear personal protective equipment (PPE).
• Avoid close body contact until treatment completes.

Infection Control (Simultaneous treatment):

• Simultaneously treat all household members (within 24 hours).
• Close contacts, and sexual partners should also be treated, even without symptoms.
• Separate belongings for decontamination.
• Decontaminate clothes, towels, and beddings used during a three-day period before treatment: Machine wash with hot water (60°C+) for more than 10 minutes and dry items for 20 minutes in dryer.
• Place non-washable items in plastic bags sealed for more than 14 days before use.

Infection Control (continued)

• For any infested patients, a single room or isolated area is recommended.

Pressure Injury

• Definition: Localized injury to skin and/or underlying tissue usually over a bony prominence resulting from pressure, or pressure in combination with shear.

Etiology

• Compression of soft tissue over bony prominence for prolonged period of time.
• Prolonged compression: occluding blood flow.
• Tissue ischaemia (lack of blood flow).
• Skin discoloration.
• Continued tissue breakdown: resulting in pressure injuries

Pressure Injury Risk Factors

• Mobility
• Skin status
• Tissue perfusion
• Blood results
• Moisture
• Temperature
• Nutrition
• Age
• Mental status
• General health status
• Quality of care

Pressure Injury Staging

• Stage 1: localized non-blanchable erythema (in darkly pigmented skin, may appear different). Sensation, temperature or firmness changes may precede visual changes.
• Stage 2: partial-thickness loss of skin with exposed dermis. Wound bed is viable (pink or red, moist), potentially present as an intact or ruptured serum-filled blister; underlying adipose tissue NOT visible. Granulation tissue, slough, and eschar are absent.
• Stage 3: full-thickness loss of skin; adipose tissue visible in ulcer. Granulation tissue is present and epibole (rolled wound edges) are visible. Slough and/or eschar are present.
• Stage 4: full-thickness skin and tissue loss; exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone are present. Slough and/or eschar may be visible; epibole (rolled wound edges), undermining and/or tunneling may occu.
• Unstageable: full-thickness loss; extent of damage obscured by slough or eschar.
• Deep Tissue Injury: intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation. Dark wound bed/blood-filled blister; pain/temperature changes may precede skin color changes in darkly pigmented skin.

Risk Assessment

• Norton Scale
• Braden Scale (used to predict pressure sore risk)

Preventive Measures

• Relieve pressure.
• Minimize friction and shearing force.
• Improve mobility; improve nutritional status.
• Minimize moisture.
• Improve sensory perception.
• Improve tissue perfusion.

Relieving Pressure

• Protective and pressure relieving devices (alternating pressure mattress, ripple bed, pillows, protectors, foam or gel positioners).
• Frequent change of position.
• Turning schedule and assessing skin condition during repositioning.
• Identifying and addressing external pressure sources (wrinkled linen/clothes, tubing, small parts). Record position changes.

Improving Mobility

• Encourage patient to remain active and ambulate.
• Remind patients to change position.
• Set up turning/exercise schedules.
• Encourage self-care activities.
• Passive ROM exercise if unable to move independently.
• Refer to physiotherapists and occupational therapists.

Improving Nutritional Status

• Adequate nutritional and fluid intake.
• High-protein diet with vitamin supplements.
• Encourage relatives to bring personal food preferences.
• Assist with feeding if needed.
• Refer to a dietitian for additional supplements.

Minimizing Moisture

• Change linen/clothes when soiled/wet.
• Maintain skin free from urine, stool, sweat and drainage.
• Dry skin thoroughly after cleansing.
• Lubricate with creams/lotions (e.g., zinc oxide).
• Topical barrier ointments.

Improving Sensory Perception

• Help patient recognize and compensate for decreased sensation.
• Educate patient and caregivers about potential pressure areas/risk for pressure ulcers.
• Encourage self-care

Improving Tissue Perfusion

• Encourage exercise, massage and maintain physically.
• Do NOT do massage of reddened areas.
• Elevate edematous body areas, protecting them from injury. (e.g., use heel protectors).