Skin Management.pptx for nursing students

for nursing students

1. Skin Management Presented by : Mrs. Azra Mahmood Lecturer FUCN

2. Objectives At the end of this presentation learners will be able to Overview skin layers Definition of bed sores Risk factors Pathophysiology Common sites of bed sores Stages /Classification of bed sores Complications, preventions and interventions Role of nurse in prevention of bed sores Braden risk assessment scale for bed sores Summarization

3. Skin The body's outer covering, which protects against heat and light, injury, and infection.  Skin regulates body temperature and stores water, fat, and vitamin D.

4. Layers of skin Skin is comprised of three major layers Epidermis Dermis Subcutaneous tissue

5. Skin layers Cont.. The  epidermis , the outermost layer of skin, provides a waterproof barrier and creates our skin tone. The  dermis , beneath the  epidermis , contains tough  connective tissue ,  hair follicles , and  sweat glands . The deeper  subcutaneous tissue  ( hypodermis ) is made of  fat  and  connective tissue .

6. Pressure ulcers/Bedsores Pressure ulcers also known as bedsores, are localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction.

7. Risk factors Friction Impaired sensory perception Impaired physical mobility Altered level of consciousness Fecal and urinary incontinence

8. Risk Factors Malnutrition Dehydration Advance age Chronic medical conditions e.g. Diabetes

9. Pathophysiology Various risk factors act on areas of soft tissue overlying bony prominence When this pressure exceeds normal capillary pressure Occlusion and tearing of small blood vessels Reduced tissue perfusion Ischemic necrosis Pressure sores / Bed sores

10. Stages /Classification of Bed Sores Staging system of bed sores is based on the depth of tissue destroyed. Based on the depth of tissue there are four stages of bed sores . Stage I Stage II Stage III Stage IV

11. Stage: I Intact skin presents with nonbalanchable erythema of a localized area usually over a bony prominence. Discoloration of skin, warmth edema or pain may also be present. Stage I indicates “At Risk “ persons. Involves only epidermal layers of the skin.

12. Stage: I

13. Stage: II A partial thickness loss of dermis presents as a shallow open ulcer with a red pink wound. Stage II is damage to the epidermis and dermis . In this stage, ulcer may be referred to as blister or abrasion.

14. Stage: III Stage III ulcer is a full thickness tissue loss. Subcutaneous fat may be visible; but bone tendon or muscle is not exposed. Epidermis ,dermis and subcutaneous tissues are involved. Subcutaneous layer has a relatively poor blood supply so it is difficult to heal.

15. Stage :IV Stage IV ulcer is the deepest, extending into the muscle ,tendon or even bone. Full thickness tissue loss with exposed muscle, bone or tendon.

16. Complications Cellulitis Bone and joint infections Sepsis Cancer

17. Bedsores are easier to prevent than to treat.

18. Preventions Position change Skin inspection Nutrition Proper hydration Lifestyle change

19. Interventions Changing positions often. Carefully follow the schedule for turning and repositioning at least once in two hours in bed . Using support surfaces . There are special cushions pads ,mattresses and beds that relieve pressure on an existing sore and help to protect vulnerable areas from further breakdown.

20. Interventions Cont... Cleaning. It’s essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with saline solution each time the dressing is changed. Removal of damaged tissue.( Debridement). To heal properly wounds need to be free of damaged , dead or infected tissue .

21. Interventions Cont… Dressings Antibiotics Healthy diet Surgical repair of tissue flap and plastic surgery

22. Role of Nurse in Management & Prevention of Bedsores The nurse should continually assess the client who are at risk for pressure ulcer development. Assess the client for predisposing factors for bedsore development. Skin condition at least twice a day . Inspect each pressure site. Palpate the skin for increased warmth.

23. Cont … Inspect for dry skin, moist skin and breaks in the skin. Evaluate level of mobility. Asses circulatory and neurovascular status.(peripheral pulses and edema) Evaluate nutritional and hydration status. Present medical condition. Assess need for incontinence management.

24. Educate the patient and family or caretaker regarding risk factors and prevention of bedsores .

25. Summarization