-
Four main functions of skin
- Protection
- Excretion/secretion
- Temperature regulation
- Sensation
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Pressure ulcer risk factors
- Confinement
- Inability to move
- Loss of elimination
- Poor nutrition
- Lowered mental awareness
-
Braden scale 6 points
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear
-
Braden scale scores
- 1-limited
- 4-fine
- at risk 15-18
- Moderate risk 13-14
- High risk 10-12
- Severe risk 9
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Pressure ulcer staging system
- I Area of red, deep pink, or mottled skin that does not blanch with fingertip pressure
- II Partial thickness skin loss involving epidermis/dermis; may look like abraison, blister, or shallow crater. Area may feel warm
- III Full thickness that may extend to fascia, subq tissue is damager or necrotic; bacterial infection is common and causes drainage; damage to surrounding skin
- IV Full thickness skin loss with extensive necrosis or damage to muscle, bone; widespread infection; may appear black and dry
- Unstageable-loss of full thickness; base covered by eschar or contains slough
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Four main purposes for bathing
- Cleanse skin
- Promote comfort
- Stimulate circulation
- Remove waste products secreted through skin
-
Unconscious patient should be provided mouth care
at least once every 8 hours; moist swabbing done every 2
-
A healthy epidermis is important because it
Acts as a barrier to entry of pathogenic organisms
-
Elderly patient's skin problems include
Nails become more brittle and thin and skin is less elastic and more fragile
-
Patient has an area at left trocanter that is reddened with slightly abraded skin has a
stage 2 pressure ulcer
-
Stage III pressure ulcer has
full thickness skin loss that looks like a deep crater
-
Partial bath includes
Face, hands, perineum and axillae
-
Prevention of pressure ulcers is promoted by
- Changing position every 2 hours
- Keeping heels off the bed
- Using lift devices to move patients
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