hygiene, personal care and prevention of ulcers

is the practice of cleanliness that is conductive to the preservation of health.

skin

maintaining safety, privacy, and warmth.

skin, hair, nails,and sweat and sebaceous glands.

• epidermis ( outer, thicker layer)
• dermis (inner, thinner layer)

• stratified squamous epithelial tissue.
• NOTE: does not contain blood vessels.

• *bottom layer of the epidermis.
• *determinant of skin color.

dense connective tissue that gives the skin strength and elasticity.

blood vessels, nerves, fibroblast, the base of hair follicles, and glands.

produce new cells after injury.

• *keratin.
• *have no nerve endings or blood supply.

secrete an oily substance called sebum.

a waxy substance secreted by the ceuminous glands; (earwax).

sweat glands.

• *line the cavities or passageways of the body that open to the outside.
• * such as the mouth, digestive, respiratory and genitourinary tract.
• *NOTE: not strictly part of the integumentary system.

• *protection
• *sensation
• *temperature regulation
• *excretion & secretion

• *protecting the body from bacteria and other invading organisms.
• *NOTE:protects tissues from thermal,chemical,and mechanical injury.

• sebum.
• *helps:limiting water absorption (swimming)
• * prevents water loss(waterproof)

• *absorbs light
• *protects against ultraviolet rays

produce vitamin D (absorbs phosphorus & calcium)

• *touch
• *pain
• *heat
• *cold
• *pressure

• *lubricates skin and hair.
• *decreases amount of heat loss & bacteria growth.

* protect against bacterial invasion, secrete mucus, and absorb fluid & electrolytes.

• * skin wrinkles & sags from the loss of fibers and adipose tissue in the dermis and subcutaneous layers.
• * skin thins & transparent.
• * fragile and slower to heal. (loss of collagen fibers)

dry itchy skin because of decreased sebaceous glands.

temperature control. Intolerance to cold: risk for exhaustion.

• *hair thinning and grows slower.
• *looses color

growing decreases and thickens.

• *sociocultural background.
• *different cultures have different views on hygiene practices.

personal preference.

assess patients ability's to provide self care by assessing cognitive & physical function. (poor vision,Muscle strength etc.)

forms from a local interference with circulation.

turn white or in darker skin become pale.

blood rushes to a place where there was a decrease of circulation.

• major factors:
• *bed/chair confinement.
• *inability to move.
• *loss of bowel or bladder control.
• *poor nutrition
• *lowered mental awareness.
• Contributing factors:
• *dehydration
• *obesity
• *excessive diaphoresis(sweating)
• *extreme age causing fragile skin
• *edema

pressure & shearing forces.

loss of bowel or bladder control

• *the softening of tissue that increases the chance of trauma or infection.
• * cause: skin that is frequently wet.

perspiration

• *assess on admission and every 24hrs.
• *commonly used tool is the Braden Scale Predicting Pressure Soar Risk.

turn patient off of redness area. Should subside with in 30-45 mins. If redness persist this means lack of blood oxygen and nutrition to area leading to necrosis(death of tissue) & ulcers.

• suspected deep tissue injury: discolored intact skin. maroon/purple or blood filled blister. Painful firm mushy warm/cold.
• stage 1:red/deep pink mottled skin, does not blanch. Darker skin;discoloration, warmth,edema or induration( area feels hard).
• stage 2:partial-thickness skin loss involving epidermis/or dermis. May look like a abrasion,blister, or shallow crater. May feel warm.
• stage3:full-thickness skin loss.looks like a deeper crater & may extend to the fascia(fibrous connective tissue). subcutaneous tissue is damaged or necrotic. Bacterial infection is common causing drainage. may be damage to surrounding tissue.
• stage 4:full-thickness skin loss w/extensive tissue necrosis, or damage to muscle, bone or supporting structures; sinus tracts. infection spread. look dry black w/build-up of tough necrotic tissue(eschar:dry scab or slough formed on the skin as a result of a burn). also wet/oozing.
• unstageable: loss of full thickness of tissue. base of ulcer is covered by eschar(tan brown black). Wound be or base contains slough (yellow tan gray green brown).

• stage1: ulcers may be just superficial or sign of deeper tissue damage.
• *are not always accurately assessed in ppl with darker skin.
• *eschar is present, cannot be staged accurately. ESCHAR MUST BE REMOVED TO STAGE ULCER.

• *excellent nursing care is the main factor.
• *Note: prevention is less time consuming & less costly than pressure ulcer treatment.

• most effective method is a team(patient family caregiver etc.) approach.
• *Note: plan goals and educate for prevention.
• *Note:initial care: debridement,wound cleaning,dressings. Also surgery.

• *assess skin
• *position @ least every 2hrs (WHEN IN BED).
• *keep heals off bed.
• *minimize friction.
• *use pressure reducing devise.(foam, pads)
• *return patient to bed after 1 hr or reposition every 1 hr.
• *self weight shifting every 15mins.
• *rub around area only.

• *skin integrity will be maintained
• *hair is clean & neatly styled
• *mouth intact & free of odor

• * chronic low self esteem
• *imbalanced nutrition: less then body requirements
• *impaired physical mobility
• *impaired skin integrity
• *ineffective peripheral tissue perfusion
• *pain acute/chronic
• *risk for impaired skin integrity
• *self care deficit, bathing/hygiene
• *self care deficit, dressing/groom
• *sensory perception, disturbed(visual)

• 105f
• 40.5c

independent patient check every 5mins. Should not exceed 15-20mins.

fainting

• cooling sponge bath
• for fevers

increase in the severity or symptoms of a disease (copd)

• safety
• privacy
• chills
• independence