Personal Hygiene, bathing And backrubs, SkinCare and pressure ulcers PN 103

Personal Hygiene The self-care measures people use to maintain the health Hygiene -The science of health -Includes care of the skin, hair, hands, feet, eyes, ears, nose, mouth , back, and perineum -Conscientious personal hygienic practices are essential for the nurse; nurses are role models

Personal Hygiene Factors influencing personal hygiene -Social practices -Body image -Socioeconomic status -Knowledge -Personal preferences -Physical condition -Cultural variables

Personal Hygiene Gerontological considerations -Older individuals have less subcutaneous tissue making them more susceptible to becoming chilled during bathing -Impaired circulation or neurological changes may decrease ability to sense temperature changes of water -Skin is often dry –no harsh soaps, no frequent bathing, use lotions and creams

Bath Administration Preparing the patient -Provide privacy (pull the curtain) -Drape as needed -Ask if he/she needs the bedpan of urinal -Arrange needed supplies -Adjust room temperature -Raise the bed to a comfortable position

Bath Administration Partial bed bath -Nurse assists the patient to bathe inaccessible body parts Complete bed bath -Reserved for patients who are completely dependent and require total assistance Shower -May be allowed if the patient is ambulatory and the MD approves Hair care -Brush or comb daily -Wash as needed

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Back Rubs -Usually administered after a patient’s bath -Promotes relaxation, relieves muscular tension, and stimulates circulation -Nurse massages for 3 to 5 minutes -Contraindicated if the patient has such conditions as fractures of the ribs or vertebral column, burns, pulmonary embolism, or open wounds

Back Rubs -Begin the massage by starting in sacral area using circular motions -Stroke upward to the shoulders -Massaging over bony prominences is no longer recommended -Evidence suggests that massage may result in decreased blood flow and tissue damage in some patients

Skin Care When a person’s physical condition changes, the skin often reflects this through alterations in: -color -thickness -texture -turgor -temperature -hydration As long as the skin remains intact and healthy, its physiological function remains optimal

Skin Care Collection of data -Normal skin has the following characteristics: -Intact without abrasions -Warm and dry -Localized changes in texture across the surface -Good turgor -Generally warm and soft -Skin color variations from body part to body part

Skin Care Impaired skin integrity -A patient who stays in one position without relief of pressure can develop a wound -also known as a pressure ulcer, PrU, decubitus ulcer or bed sore Patients at risk -chronically ill -debilitated -older -disabled -incontinent -patients with spinal cord injuries -limited mobility -poor overall nutrition

Pressure Ulcers Pressure Ulcer Risk Assessment Tools -Braden Scale and Norton Scale -the lower the score on both tools, the higher the pressure ulcer risk -the total annual cost of treating a pressure ulcer in the US is approximately $8.5 billion -1.7 million people develop pressure ulcers each year

Braden Scale

Norton scale

Pressure Ulcers Pressure ulcers occur when there is sufficient pressure on the skin to cause the blood vessels in an area to collapse The flow of blood and fluid to the cells is impaired, resulting in ischemia to the cells When external pressure against the skin is greater than the pressure in the capillary bed, blood flow decreases to the adjacent tissue If the pressure continues for longer than 2 hours, cell necrosis occurs

Pressure Ulcers Shearing force -An internal, opposing motion of tissue layers and bone. Shearing forces stretch or tear the blood vessels which reduces the amount of pressure needed to occlude them Friction -Rubbing of skin over a surface produces friction, which may remove layers of skin

Pressure Ulcers Maceration/Incontinence -Continued exposure of skin to moisture, causing tissue softening which leaves the skin more susceptible to the forces of shear and friction Epidermal stripping -Removal of the top layer of skin by mechanical forces -tape burns

Shearing force

Skin structure

Stage of Pressure ulcers Stage I -nonblachable erythema of the skin Stage II -partial skin loss of the epidermis Stage III -full thickness skin loss, damage or necrosis of the subcutaneous tissue Stage IV -full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures

Pressure Ulcers Nursing Interventions -Assess improvement -Assess size and depth of the ulcer -the amount and color of the exudate -the presence of pain or odor -the color of the wound -the appearance of the surrounding tissue -Specific interventions are determined by the stage of the ulcer

Stage I pressure ulcer

Stage I pressure ulcer Treatment: -Relieve pressure -Monitor closely as may progress to another stage even after pressure is remove

Stage ii Pressure ulcer

Stage ii Pressure ulcer Treatment: -Remove pressure -Clean with facility approved wound cleanser or normal saline -Debride any necrotic tissue (chemically, mechanically or surgically) -Keep moist healing environment by covering with alginate, gel or hydrocolloid dressing -Change dressing 1-2 times a day.

Stage III pressure ulcer

Stage iv pressure ulcer

Stage III & iv pressure ulcer Treatment: -Remove pressure -Cleanse wound with facility approved wound cleanser or irrigate with normal saline -Debride any necrotic tissue -Fill any dead space (pack lightly with moist gauze), use wound gel and/or moist dressings -May consider wound vac when the necrotic tissue is debrided and granulating tissue has filled the wound

Pressure Ulcers Support surfaces -Pressure relieving mattresses or chair cushions should be used with patients who are at risk for skin impairment -alternating air mattresses -silicone mattresses

Pressure Ulcers http://mcom.alexanderstreet.com/view/1665674/play/true/

Prevention of Pressure Ulcers Positioning -use positioning devices (pillows, foam wedges) to prevent bony prominence from direct contact with any other surface -turn and reposition bedbound patients at least every 2 hours Seating interventions -Shift weight every 15 minutes -if unable to shift weight, reposition every hour -wheelchair cushion

Prevention of Pressure Ulcers Moisture reduction -Incontinent patients should be checked for incontinence every 2 hours and changed as soon as incontinence has occurred -use barrier ointment to skin at perineum Range of motion -Helps keep the blood circulating and keeps the patient from being in one position

Prevention of Pressure Ulcers Prevent shear and friction -Nutrition -All at risk patients should be referred to a dietician for nutritional interventions -Vitamin and mineral supplements as ordered by the patient’s HCP