Skin Integrity and Wound Care (2019-2020) - Tishk International University PDF

Tishk International University Nursing Faculty Nursing Department Fundamental of Nursing Skin Integrity and Wound Care First Grade – Spring Semester 2019-2020 Instructor: Halmat Authman Rasheed LEARNING OUTCOMES Risk factors of pressure ulcer. Stages of pressure ulcer. FECAL AND URINARY INCONTINENCE...

Tishk International University Nursing Faculty Nursing Department Fundamental of Nursing Skin Integrity and Wound Care First Grade – Spring Semester 2019-2020 Instructor: Halmat Authman Rasheed LEARNING OUTCOMES Risk factors of pressure ulcer. Stages of pressure ulcer. 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. excoriation (area of loss of the superficial layers of the skin; also known as denuded area). Any accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection DECREASED MENTAL STATUS Those who are unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers. because they are less able to recognize and respond to pain associated with prolonged pressure. DIMINISHED SENSATION Paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area. Loss of sensation reduces a person’s ability to respond to trauma, to injurious heat and cold, and to the tingling that signals loss of circulation EXCESSIVE BODY HEAT An elevated body temperature increases the metabolic rate, thus increasing the cells’ need for oxygen. This increased need is particularly severe in the cells of an area under pressure, which are already oxygen deficient. ADVANCED AGE The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity. These changes include the following Loss of lean body mass Generalized thinning of the epidermis Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch Diminished venous and arterial flow due to aging vascular walls CHRONIC MEDICAL CONDITIONS Diabetes and cardiovascular disease are risk factors for skin breakdown and delayed healing Other factors Poor lifting and transferring techniques, incorrect positioning, hard support surfaces, Stages of Pressure Ulcers Stage I: Non-blanchable erythema signaling potential ulceration Stage II Partial-thickness skin loss ( a b r a s i o n , b l i s t e r, o r shallow crater) involving the epidermis and possibly the dermis. Stage III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Stage IV Full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule Unstageable/unclassified Full-thickness skin or tissue loss— depth unknown: Actual depth of the ulcer is completely obscured by slough. Suspected deep tissue injury Depth unknown: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear