Skin Assessment and Decubitus ulcer prevention

 

Impaired Skin Integrity Assessment

  • pressure ulcers

 

Risks:

  • those confined to bed for long periods
  • those with motor or sensory dysfunction
  • patients with muscular atrophy
  • those with reduced tissue b/t bone and skin

 

Occur:

  • localized areas of infarcted tissue
  • occur when pressure is applied to skin over time resulting in greater than normal capillary closure pressure.
  • Critically ill pts have lower capillary pressure

 

Initial signs of pressure sores are:

  • erythema – d/t reactive hyperemia which normally resolves in less than an hour

 

  • unrelieved pressure results in tissue ischemia or anoxia
  • cutaneous tissue breakdown
  • followed by destruction and necrosis of underlying tissue

 

Assessment for risk factors:

  1. Immobility
  2. Impaired sensory perception or cognition
  3. Decreased tissue perfusion
  4. Decreased Nutritional Status
  5. Friction and shear forces
  6. Increased moisture
  7. Age-related skin changes

 

Immobility

  • Duration of immobility related to pressure sore development
  • weight-bearing bony prominences are most susceptible
  • eg sacrum. Coccyx, tuberosities

 

Sensory impairment

  • sensory loss
  • decreased consciousness
  • paralysis
  • may not be aware of discomfort associated with prolonged pressure on the skin

 

Decreased tissue perfusion

  • any condition that reduces circulation and nourishment of the skin and subcutaneous tissues
  • altered peripheral perfusion increases risk
  • eg diabetes, obesity and edema

 

Altered nutritional status

  • deficiencies
  • anemias – dec blood O2 carrying capacity
  • metabolic disorders
  • low protein levels and neg nitrogen balance cause delayed repair

 

Friction and shear

  • causes vessels to twist and blood supply to be disrupted
  • occurs when patient slides down in bed

 

Increased moisture

  • tissue masseration
  • skin irritants
  • increased susceptibility to pressure sores’
  • open skin is invaded by microbes

 

Geriatrics

  • have decreased epidermal layer
  • decreased tissue perfusion
  • decreased sweat gland activity
  • diminished sensory perception

 

Assess for pressure sore development

  1. Assess total skin condition BID
  2. Inspect each pressure site for erythema
  3. Assess erythematous site for blanching response
  4. palpate skin for increased warmth
  5. Inspect for dry, moist skin and breaks
  6. note drainage and odor
  7. evaluate level of mobility
  8. note restrictive devices – splints and restraints
  9. evaluate circulatory statusperipheral pulses and edema
  10. Assess neurovascular status
  11. determine presence of incontinence
  12. evaluate nutritional and hydration status
  13. review patient’s record – Hb, electrolytes, albumin, transferrin and creatinine
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