1. Jane Gosche Director of Nursing Klemzig Residential Care Facility

2. SKIN BY DEFINITION: Our Skin is the largest organ of our body The Skins functions include - Protection Helps regulate body temperature Produces and absorbs Vit. D It is an excretory organ Transmits sensation

3. INTEGRITY BY DEFINITION: From the Macquarie Dictionary The state of being whole, entire or undiminished, unimpaired or perfect condition. In other words Whole and Complete! Our assessment of a residents skin integrity is like putting a jigsaw puzzle together.

4. NORMAL BIOLOGICAL AGEING: Our skin becomes thin and dry and is therefore at risk of tearing and bruising. Our skin looses elasticity resulting in more skin folds.

5. 1)To establish risk factors. 2)To assess individual residents skin integrity. 3)To implement a process for prevention of loss of skin integrity. 4) Review current statistics and risk assessment interventions. 5) To promote optimum quality of life for residents.

6. 1) EXTERNAL RISK FACTORS: Pressure- the constant pressure on an area of the body caused by the inability of a person to reposition them self physically. Shearing- force of skin sliding against internal surface. Friction- movement between the skin and contact surface. Moisture- excessive external moisture on the skin.

7. 2)INTERNAL RISK FACTORS: Age, as discussed, the changes in skin integrity. Chronic Illness, may impact on the skins ability to maintain normal functioning. Altered cognitive status, a persons inability to be aware of repositioning. Immobility, inability to reposition. Diminished sensation, inability to feel pain or discomfort. Circulatory Impairment, risk of skin break down.

8. 3)On admission complete: Initial Health Assessment and formulate a care plan- This includes a thorough skin assessment to establish a baseline. Complete continence assessment – Assess continence pads and toileting regime. Assess for use of protective moisture barrier cream, disposable wipes and no rinse cleanser if required for incontinence.

9. Behaviour Identification – assess for potential at risk behaviours that could skin trauma, eg. Repetitious movements causing friction / shear, or non compliance with activities of daily living. Safety - assess for safety interventions required. It is well documented that the use of restraint can cause more damage to skin integrity than no restraint. ADL`s Meals and Drinks – assess type of diet and fluids required as well as amount of assistance and encouragement. Commence supplements if under weight, weigh weekly or monthly.

10. ADL`s Personal Hygiene – Individually assessed daily hygiene needs of a persons skin integrity, shower / sponge, Dermalux hot towel bath, or for very frail residents a shower bath is used. no soap, residents use ph balanced shower lotion. Application of moisturiser for dry skin. Daily inspection of skin and skin folds. Pain assessment – type and location. Transfer and Mobility – Links with physio assessment and a persons ability to mobilise. We promote optimum mobility therefore need to use protection on skin integrity; use of film dressing, leg, arm and hip protectors

11. Medication assessment – potential for thinning and bruising of skin. Mini Mental – establish cognitive awareness. Depression Scale – potential for sedentary lifestyle or self harm. Physiotherapy – links with mobility, promotion of optimum range of movement and flexibility through an exercise program. This is conducted at hygiene time when the skin, muscles and joints are warm. Podiatry – establish any foot abnormalities.

12. Braden Scale selected as best practise in aged care as it incorporates – Moisture, Activity, Mobility, Nutrition, Friction and Shear. Interventions required by level of risk assessed – Low Risk – 20 – 23 Moderate Risk – 16 – 19 High Risk - 11 – 15 Very High Risk - 6 – 10

13. Monthly Skin Tear Statistics – broken down to per resident; September 2005, 13 x skin tears on 11 residents, 4 x falls, 2 x CVA rehabilitation promoting independence, 3 x very frail skin, 3 x resident behaviours, 1 x CVA resident unaware of paralysed arm. Monthly Incident Statistics includes time of incident, environmental design, staff actions, resident actions, fall, injury etc. Facility audit of current mattresses, now replacing inadequate with high density foam pressure relieving mattresses monthly. All residents to sit on egg shell foam cushions when on hard surface chair / wheelchairs. Currently linking international nutrition scale with Braden scale.

14. Assessment on admission. Three monthly assessments to review all cares thereafter. Review if any change to health status at any time, post hospitalisation and post surgery. We aim to promote maximum independence, self esteem, skin integrity and quality of life in a home like environment. As you can see the jigsaw fits together.