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1.1 Describe the anatomy and physiology of healthy skin.
Skin is the largest organ of the body, covering and protecting the entire surface of the body.
The total surface area of skin is around 3000 sq inches or roughly around 19,355 sq cm depending on age, height, and body size. The skin, along with its derivatives, nails, hair, sweat glands, and sebaceous glands forms the integumentary system. Besides providing protection to the body the skin has a host of other functions to be performed like regulating body temperature, immune protection, sensations of touch, heat, cold, and pain through the sensory nerve endings, communicating with external openings of numerous other body systems like digestive system, urogenital system, and respiratory system via mucous membranes.
The skin is primarily composed of three layers.
The skin, which appears to be so thin, is still itself divided into epidermis, dermis, and subcutaneous layer or hypodermis. Each layer has it own function and own importance in maintaining the integrity of skin and thereby the whole body structure.
Pressure sores or decubitus ulcers are the result of a constant deficiency of blood to the tissues over a bony area such as a heel which may have been in contact with a bed or a splint over an extended period of time. The surface of the skin can ulcerate which may become infected. Eventually subcutaneous and deeper tisssues are damaged. Besides the heel, other areas commonly involved are the skin over the buttocks, sacrum, ankles hips and other bony sites of the body.
1.2 Describe the changes that occur when damage caused by pressure develops early signs of pressure sites are redness that doesnt fade rapidly, heat and/or swelling when pressure is relieved. there may be callous formation that has flaky skin around it and a “mushy” feeling when surrounding skin is palpitated. blisterlike eruptions can develop and become a profound wound if pressure relief techniques are not used conscientiously. Then you better study real hard because your patients are relying on you to help them. Hope you pass your test.
1.3 explain when an initial tissue viabilitiy risk assessment may be required. It is important when a person enters a new care setting that an assessment of their pressure ulcer risk is carried out. This assessment should take place as soon as possible, as pressure ulcers can develop quickly. It is also important to remember that a person’s condition can change which may mean a change in their pressure ulcer risk. It is good practice to re-assess a person’s risk of developing a pressure ulcer when there is a change in their condition. In order to identify quickly a change in a person’s pressure ulcer risk, undertake an assessment of pressure ulcer risk on a daily basis.
1.4 Describe wot to look for when assessing the skin
Always use a single-use, metric tape measure. Never measure using “coins” (dime-sized, quarter-sized, etc.). Measurements should be done at least weekly.
Length: Linear distances from wound edge to wound edge. To measure consistently, look at the wound as if it were a clock face: the top of the wound (12 o’clock) is toward the patient’s head. The bottom of the wound (6 o’clock) is toward the patient’s feet. Length is the longest distance measured from 12 to 6 o’clock. Width: Width is longest distance measured from side to side, or from 9 to 3 o’clock. Depth: The distance from the visible surface to the deepest point in the wound base. Measure depth using a cotton-tip applicator, holding it perpendicular to the wound edge, placing the finger at the point on the swab that corresponds to the wound edge. While still holding this measurement, remove the swab and measure it on the tape measure. Undermining: Use a cotton-tip applicator to probe to the deepest part of the undermining.
Mark the depth between the end of the applicator and the wound edge with the finger and measure it against the tape measure. Describe the location of the undermining using the clock face (e.g., “undermining extends from 12 o’clock to 5 o’clock and is deepest at 3 o’clock at 3 cm”). Tunneling or sinus tract: Measure the tract as for undermining and describe its location using the clock face. Wound care documentation includes a variety of information that reflects the wound status while it heals. Providing an accurate description of the skin and wound characteristics is critical following each dressing change. These findings of the ulcer’s current status will help the clinician in revising the plan of care and treatment strategies over time.
2.1 Identify individuels who may be at risk of impared tissue viability and skin breakdown. Certain groups of patients have a higher risk for developing pressure ulcers. These include:
Patients who are older adults (those over age 65 are at high risk and those over age 75 are at even greater risk)
Patients in critical care
Patients with a fractured hip (an increased risk for heel pressure ulcers) Patients with spinal cord injuries (spasticity, the extent of the paralysis, a younger age at onset, difficulty with practicing good skin care, and a delay in seeking treatment or implementing preventive measures increase the risk of skin breakdown) Individuals with diabetes, secondary to complications from peripheral neuropathy Individuals who are wheelchair- or bed-bound
Patients who are immobile or for whom moving requires significant or taxing effort (i.e., morbidly obese)
Patients who struggle with incontinence
Patients with neuromuscular and progressive neurological disesases (i.e., multiple sclerosis, ALS, Myasthenia gravis, stroke)
4.1 Explain why the tissue viability risk assessement should be regulary reviewed and repeated. There are several tools for assessing pressure ulcer healing. The Bates-Jensen Wound Assessment Tool (BWAT) is comprised of fifteen items, of which thirteen are scored from 1–5. The total scores and dates of assessment can be plotted on a graph, which provides an index of improvement or deterioration of the wound. (See “Resources” at the end of this course.) The PUSH tool (Pressure Ulcer Scale for Healing) was developed by NPUAP. An ulcer is categorized using numerical scores of 0–5 according to surface area (length times width), drainage amount, and tissue type.
A comparison of the total scores measured over time provides an indication of improvement or deterioration in the ulcer. Many computer systems also have programs to monitor ulcer progress. Of course, the clinician will also use clinical judgment to assess signs of healing, such as a decrease in the amount of drainage, pain, and wound size and an improvement in wound bed tissue. The clinician can also use photography, comparing baseline and serial photographs to monitor healing over time. Follow facility policy on the use of photography.
4.2 Explain when the tissue viability assessment tool, or the curent review cycle may no longer be appropriate due to changes in the individuals condition or enviroment.
NUTRITION ASSESSMENT PARAMETERS
Current weight and usual weight
History of unintentional weight loss or gain (>5% change in 30 days or >10% change in 180 days)
Body mass index (BMI)
Ability to chew, swallow, and feed oneself
Medical and/or surgical history that influences intake or absorption of nutrients
Psychosocial factors that can affect food intake
Ability to obtain and pay for food
Facilities for cooking and eating
Cultural and lifestyle influences on food selection
Over 65 years of age
The patient should be monitored for signs of dehydration, such as decreased skin turgor and/or urine output or elevated serum sodium. Serum protein tests, such as for albumin and pre-albumin, may be affected by inflammation, renal function, and hydration and so may not correspond with overall nutritional status. Thus, laboratory tests should be considered as only one part of the nutritional assessment.
While there is evidence that adequate nutritional support for stage III and IV pressure ulcers is a strong predictor of pressure ulcer healing and that support with high protein can significantly reduce the risk of pressure ulcers, there is no evidence to support that specific supplements promote the healing of ulcers. Studies that show support are few and more research needs to be done (WOCN, 2010). Any patient with nutritional and pressure ulcer risks, suspected or identified nutritional deficiencies, or a need for nutritional supplementation to prevent undernutrition should be referred to a registered dietician. Any patient with a pressure ulcer should be referred to the dietician as well (WOCN, 2010).
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