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5.02 ppt skin integrity
- 1. Understand nurse aide skills needed to promote skin integrity. Unit B Resident Care Skills Essential Standard NA5.00 Understand nurse aide’s role in providing residents’ hygiene, grooming, and skin care. Indicator 5.02 Understand nurse aide skills needed to promote skin integrity. 15.02 Nursing Fundamentals 7243
- 2. 25.02 Nursing Fundamentals 7243 As a direct care giver, the nurse aide will be the key team member in the prevention of pressure ulcers. 5.02 Introduction
- 3. Nursing Fundamentals 7243 3 PRESSURE ULCERS AKA: Bedsores Decubitus Ulcers 5.02
- 4. Nursing Fundamentals 7243 4 PRESSURE ULCERS Caused by pressure on area of skin that interferes with circulation 5.02
- 5. BRAIN STORM 5 Think What does circulation provide for tissues? Act Raise your hand and share your thoughts! Wait to be called on. Nursing Fundamentals 72435.02
- 6. Nursing Fundamentals 7243 6 PRESSURE ULCERS Occur where bones come close to the skin surface or bony prominences. 5.02
- 7. Nursing Fundamentals 7243 7 PRESSURE ULCERS –toes, heels, ankles, knees –hips, elbows, shoulders –spine (especially tailbone area) –ears, cheeks, collarbone area –back of head 5.02
- 8. Nursing Fundamentals 7243 8 PRESSURE ULCERS Can develop where areas of body rub together and moisture collects, especially in obese residents 5.02
- 9. Nursing Fundamentals 7243 9 PRESSURE ULCERS –Under breasts –Between folds of abdomen –Between crease of buttocks –Between thighs 5.02
- 10. Nursing Fundamentals 7243 10 PRESSURE ULCERS 1 OUNCE PREVENTION 1 POUND CURE 5.02
- 11. Nursing Fundamentals 7243 11 PRESSURE ULCER PREVENTION Keep skin clean and dry! 5.02
- 12. Nursing Fundamentals 7243 12 PRESSURE ULCER PREVENTION Keep linen dry and free of wrinkles and objects that cause pressure to the skin! 5.02
- 13. Nursing Fundamentals 7243 13 PRESSURE ULCER PREVENTION Clean urine and feces from skin as soon as possible!5.02
- 14. Nursing Fundamentals 7243 14 PRESSURE ULCER PREVENTION Reposition residents at least every two hours! 5.02
- 15. Nursing Fundamentals 7243 15 PRESSURE ULCER PREVENTION Make sure clothing and shoes do not bind or constrict! 5.02
- 16. Nursing Fundamentals 7243 16 PRESSURE ULCER PREVENTION Pat skin dry when bathing; never scrub. 5.02
- 17. Nursing Fundamentals 7243 17 PRESSURE ULCER PREVENTION Encourage adequate nutrition and fluids! 5.02
- 18. Nursing Fundamentals 7243 18 PRESSURE ULCER PREVENTION Massage healthy skin and tissue around the area. 5.02
- 19. Nursing Fundamentals 7243 19 PRESSURE ULCER PREVENTION Massage skin often. Use light circular stroke to increase circulation. 5.02
- 20. Nursing Fundamentals 7243 20 PRESSURE ULCER PREVENTION Use little or no pressure on bony areas.5.02
- 21. Nursing Fundamentals 7243 21 PRESSURE ULCER PREVENTION Do NOT massage a white, red, or purple area or put any pressure on it.5.02
- 22. Nursing Fundamentals 7243 22 PRESSURE ULCER PREVENTION Be careful during transfers. Avoid pulling or tearing fragile skin. 5.02
- 23. Nursing Fundamentals 7243 23 PRESSURE ULCER PREVENTION Take YOUR jewelry off! This is just like a knife! 5.02
- 24. Nursing Fundamentals 7243 24 PRESSURE ULCER PREVENTION Keep YOUR nails short! This is just like a knife! 5.02
- 25. Nursing Fundamentals 7243 25 PRESSURE ULCER PREVENTION Keep YOUR nails short! This is safe. 5.02
- 26. 26 IMMEDIATELY ANY CHANGE IN SKIN CONDITION! 5.02 Nursing Fundamentals 7243
- 27. Nursing Fundamentals 7243 27 PRESSURE ULCER PREVENTIVE DEVICES Bed cradle Heel and elbow protectors Flotation pads or cushions Pillows Water beds Alternating pressure mattresses Eggcrate mattresses 5.02
- 28. Nursing Fundamentals 7243 28 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage One - red, darkened or non-blanchable skin, which is still present 30 minutes after pressure relieved 5.02
- 29. Nursing Fundamentals 7243 29 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage One position off area and report; do not massage observe every 2 hours and report changes to supervisor 5.02
- 30. Stage 1 pressure ulcer
- 31. Nursing Fundamentals 7243 31 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Two - addition of blister-like lesions; skin may be broken 5.02
- 32. Nursing Fundamentals 7243 32 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Two • position off area at all times, • report need for dressing changes • report odor, drainage, any change in size 5.02
- 33. Stage 2 pressure ulcer
- 34. Nursing Fundamentals 7243 34 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Three - skin tissue is destroyed and fatty tissue may be involved; infection and eschar (scab) may result 5.02
- 35. Nursing Fundamentals 7243 35 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Three continue prevention practices report any changes in area 5.02
- 36. Stage 3 pressure ulcer
- 37. Nursing Fundamentals 7243 37 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Four - skin, fatty tissue destroyed and muscle and bone involved! 5.02
- 38. Nursing Fundamentals 7243 38 Pressure Ulcers: Stages Of Tissue Breakdown And Treatment Stage Four report any signs of systemic infection, including but not limited to: • wound odor • pain • elevated temperature with confusion 5.02
- 39. Stage 4 pressure ulcer
- 40. equipment • Elbow pads • Heel booties • Bed cradle • Footboard • Pressure relieving mattress • Specialty beds – Airflow – Alternating pressure – Wedge turning
- 41. Nursing Fundamentals 7243 41 POSITIONING 5.02
- 42. F Y I - Intentional Repeat There is intentional repeat of some HSII course content in Nursing Fundamentals. Repeating course content distributes learning over time and increases long term memory. Academic and skill competence must be maintained at a very high level for direct resident care. 42Nursing Fundamentals 72435.02
- 43. Nursing Fundamentals 7243 43 POSITIONING Purposes: • Assist with examinations • Assist with procedures • Prevent pressure on skin for prolonged periods of time 5.02
- 44. Nursing Fundamentals 7243 44 POSITIONS Dorsal recumbent position flat on back knees slightly separated and flexed feet flat on bed http://www.wisc- online.com/objects/ViewObject.aspx?ID=ME A1604 5.02
- 45. Nursing Fundamentals 7243 45 POSITIONS Horizontal recumbent position – supine flat on back legs slightly separated and extended http://www.wisc- online.com/objects/ViewObject.aspx?ID=M EA1604 5.02
- 46. Nursing Fundamentals 7243 46 POSITIONS Prone position flat on abdomen with head turned to side arms at sides or flexed on either side of head http://www.wisc- online.com/objects/ViewObject.aspx?ID=M EA1604 5.02
- 47. Nursing Fundamentals 7243 47 POSITIONS Side lying position positioned on either side head in straight line with spine pillows used to support head, back, arm, and leg http://www.wisc- online.com/objects/ViewObject.aspx?ID=MEA1604 5.02
- 48. Nursing Fundamentals 7243 48 POSITIONS Lateral position positioned on either side bottom arm extended behind back, top arm flexed in front of body top leg slightly flexed http://www.wisc- online.com/objects/ViewObject.aspx?ID=MEA1604 5.02
- 49. Nursing Fundamentals 7243 49 POSITIONS 30 Lateral Reclined Position hips rotated 30 degrees pillow between knees pillow under arm for comfort and to relieve pressure on elbow pressure relieved from sacrum and http://www.wisc- online.com/objects/ViewObject.aspx?ID=MEA1604 hip 5.02
- 50. Nursing Fundamentals 7243 50 POSITIONS Fowler’s position sitting position in bed with head elevated at 45-60 degree angle. knees slightly flexed position causes pressure on sacrum and buttocks http://www.wisc- online.com/objects/ViewObject.aspx?ID=MEA1604 5.02
- 51. Nursing Fundamentals 7243 51 POSITIONS Sim's position positioned on LEFT side left arm extended behind body right arm flexed in front of body right leg flexed toward abdomen used for enema administration http://www.wisc- online.com/objects/ViewObject.aspx?ID=MEA1604 5.02
- 52. Nursing Fundamentals 7243 52 POSITIONS Sim's position Best position for enemas 5.02
- 53. Nursing Fundamentals 7243 53 TURNING POSITIONING LIFTING MOVING 5.02
- 54. Nursing Fundamentals 7243 54 Moving, Turning, Positioning And Lifting Good body mechanics necessary Prevents injury to resident Protects nurse aide from injury Good body alignment Promotes comfort for resident 5.02
- 55. Nursing Fundamentals 7243 55 Moving, Turning, Positioning And Lifting Safety major considerations Get help if needed Receive directions from supervisor regarding any restrictions for positioning or movement 5.02
- 56. Nursing Fundamentals 7243 56 Moving, Turning, Positioning And Lifting Safety major considerations Protect and secure any special equipment being used by the resident prior to movement (e.g., drainage tubes). Elevate bed to comfortable working level 5.02
- 57. Nursing Fundamentals 7243 57 Moving, Turning, Positioning And Lifting Safety major considerations Protect skin from friction roll when possible lift with assistance prevent sliding use turning sheet 5.02
- 58. Nursing Fundamentals 7243 58 Moving, Turning, Positioning And Lifting Use postural supports as directed: Rolled blankets Pillows Rolled towels Footboards Bed cradles 5.02
- 59. Nursing Fundamentals 7243 59 Moving, Turning, Positioning And Lifting Reposition at least every two hours or as directed Eliminates pressure on bony areas Provides comfort Exercises muscles Moves joints Stimulates circulation 5.02
- 60. Nursing Fundamentals 7243 60 Moving, Turning, Positioning And Lifting Coordinate lifting and moving Move on a certain count, usually count of three Gain cooperation of resident Have residents help themselves as much as possible 5.02
- 61. Nursing Fundamentals 7243 61 Moving, Turning, Positioning And Lifting Coordinate lifting and moving (continued) Use transfer belt (gait belt) when appropriate When in doubt, always ask for assistance from co-workers 5.02
- 62. 5.02 Nursing Fundamentals 7243 62 SKILL 5.02A Moving Resident Up in Bed with/without Turn Sheet Training Lab Assignment Engage in the Skill Acquisition Process for:
- 63. 5.02 Nursing Fundamentals 7243 63 SKILL 5.02B Positioning Resident on Side Training Lab Assignment Engage in the Skill Acquisition Process for:
- 64. Nursing Fundamentals 7243 64 Repositioning Resident In Chair Or Wheelchair 5.02
- 65. Nursing Fundamentals 7243 65 Repositioning Resident In Chair Or Wheelchair Reasons for changing position every two hours or as directed Promotes comfort Reduces pressure Increases circulation Exercises joints Promotes muscle tone 5.02
- 66. Nursing Fundamentals 7243 66 Repositioning Resident In Chair Or Wheelchair Body kept in good alignment with head in straight line with spine Plastic or vinyl surface of chair covered, with use of pressure- relieving cushion preferred Pillows or soft blankets used for support 5.02
- 67. Nursing Fundamentals 7243 67 Repositioning Resident In Chair Or Wheelchair Feet REST on floor or footrest of wheelchair 5.02
- 68. Nursing Fundamentals 7243 68 Repositioning Resident In Chair Or Wheelchair Hips positioned well back in chair 5.02
- 69. Nursing Fundamentals 7243 69 Repositioning Resident In Chair Or Wheelchair Weight shifting utilized in between repositioning 5.02
- 70. BRAIN STORM 70 Think Why shift weight? Act Raise your hand and share your thoughts! Wait to be called on. Nursing Fundamentals 72435.02
- 71. 5.02 Nursing Fundamentals 7243 71 Other Nurse Aide Skills that Promote Skin Integrity http://www.webmd.com/skin-problems-and-treatments/slideshow-common-adult-skin-problems Applying Non-Sterile Dressing Applying Warm and Cold Therapy
- 72. Nursing Fundamentals 7243 72 • Covering applied to wound or injured body part where slight risk of infection or re-injury • Materials come in various types and sizes: –Gauze pads –Band-aids –Thick compresses APPLYING NON-STERILE DRESSINGS 5.02
- 73. 5.02 Nursing Fundamentals 7243 73 Related SKILL
- 74. 5.02 Nursing Fundamentals 7243 74 SKILL 5.02C Apply Non-Sterile Dressing Training Lab Assignment Engage in the Skill Acquisition Process for:
- 75. Nursing Fundamentals 7243 75 • Requires physician’s order for type of therapy and length of time for application WARM AND COLD THERAPY 5.02
- 76. Nursing Fundamentals 7243 76 • Purposes and Effects –WARMTH: dilates blood vessels •increased blood supply to area •blood brings oxygen & nutrients for healing •fluids are absorbed •muscles relax •pain relieved WARM AND COLD THERAPY 5.02
- 77. Nursing Fundamentals 7243 77 • Purposes and Effects –COLD: constricts blood vessels • decreased blood supply to area • prevents swelling • controls bleeding • numbs skin, reducing pain • reduces body temperature WARM AND COLD THERAPY 5.02
- 78. Nursing Fundamentals 7243 78 • Dry cold - water does not touch skin –ice bags –ice caps –ice collars –disposable cold pack TYPES OF WARM AND COLD THERAPY 5.02
- 79. Nursing Fundamentals 7243 79 • Moist cold - water touches skin –compresses – localized application –soaks - body part immersed in water –cool sponge bath TYPES OF WARM AND COLD THERAPY 5.02
- 80. Nursing Fundamentals 7243 80 • Dry warmth – pads with circulating warm water • Moist warmth –compresses –soaks –sitz bath TYPES OF WARM AND COLD THERAPY 5.02
- 81. Nursing Fundamentals 7243 81 –Use bath thermometer to measure the temperature of moist heat solutions. –Do not operate equipment you have not been trained to use. –Temperature never over 105° F. Check skin frequently and report any signs of complications. GUIDELINES FOR WARM THERAPY 5.02
- 82. Nursing Fundamentals 7243 82 –Apply ice caps with metal or plastic lids away from skin –Cover ice caps/bags/collars prior to application –Check skin frequently and report any signs of complications –Never leave in place longer than directed by supervisor GUIDELINES FOR COLD THERAPY 5.02
- 83. 5.02 Nursing Fundamentals 7243 83 Related SKILL
- 84. 5.02 Nursing Fundamentals 7243 84 SKILL 5.02D Apply Warm and Cold Applications Training Lab Assignment Engage in the Skill Acquisition Process for:
- 85. The Bottom Line 5.02 Nursing Fundamentals 7243 85 Skin is the body’s first line of defense against disease. Maintain the integrity of the skin.
- 86. Understand nurse aide’s role in promoting skin integrity. 86 END 5.02 5.02 Nursing Fundamentals 7243
Editor's Notes
- A reddened area that doesn’t return to normal color after the pressure is removed The reddened area may later become very pale or white, and shiny
- Looks like a blister, an abrasion, or a shallow crater The epidermis peels away or cracks open which creates a portal of entry for pathogens The dermis may be partially worn away as well
- The epidermis and dermis is gone and the subcutaneous fat may be visible in the crater There may be drainage from the wound
- The crater of damaged tissue extends all the way through the tissues to the muscle or bone