Skin Integrity

The following Learning resource will help you to develop knowledge regarding skin integrity.

Informational content and interactive learning will cover:

 

* The anatomy and function of the skin (A recap).

* Definitions of skin integrity and why its maintenance is so important.

* Definitions of pressure ulcers.

* Intrinsic and extrinsic risk factors.

* Assessment of patients' skin integrity  

* Assessment and  grading of pressure ulcers.

* Patient management.

Skin Integrity and Patient assessment.

Overview of the anatomy and function of the skin (A recap).

How do we maintain good skin integrity?

Skin integrity and pressure ulcers. Our role as nurses

Now that you have watched the video, let's see what you have learnt.....

Where do patients most commonly develop pressure areas?

Consider the body chart below.  Assuming that the patient is laying supine in the first image and on their side in the second image, highlight where they are most at risk of developing pressure areas (by clicking to pinpoint).


Here's a helpful learning resource.  It includes a helpful diagram and other useful information.

http://thehearingaidpodcasts.org.uk/episode-3-3-preventing-pressure-ulcers/



Further information

Risk factors (Intrinsic and Extrinsic) (to complete)

Assessing patients: How to complete a "Waterlow" chart

Use the knowledge you have gained from the video, to assess Mrs Blake and generate a Waterlow score.

This is Mrs Blake:

Mrs Blake is a 77 year old lady who has been admitted to your ward following a fall at home. Unfortunately, the fall resulted in a fractured hip.  Although Mrs Blake is in good spirits, she hasn't eaten anything since her admission, specifying that she doesn't have a particularly good appetite lately, but drinks plenty of cups of tea.  She mentions that she has lost weight recently as she previously weighed 56kg and now weighs just 51kgs. Nevertheless, Mrs Blake has maintained an normal Body Mass Index due to her height. 

You use a unified assessment to gain further information about Mrs Blake. You establish that she is incontinent of urine at night, for which she wears incontinence pads. Upon inspection of her skin, you can see that there are no broken areas, but that Mrs Blake has dry skin in some places.

3 years ago, Mrs Blake was diagnosed with Arterial Fibrillation and was therefore advised to quit smoking.  She has managed to cut down to 5 cigarettes per day instead of 20.

Task 1:

Complete a "Waterlow" chart for Mrs Blake and generate a score to establish whether Mrs Blake is at "High Risk", "Medium Risk" or "Low risk" of developing a pressure ulcer.   You are required to pinpoint (by clicking on the numbers) relevant areas of the assessment to generate the correct score. Make a note of the scores as you go along. You are then required to specify the level of risk by clicking on the relevant outcome on the chart (Bottom left).


Hint:

There should be 11 areas highlighted on the chart, including the final identification of Mrs Blakes risk.


Interventions (Learning content). What can we do for our patients?

Skin care Bundles.

The link below provides some useful information regarding Skin Care bundles, which are tools to assist with preventing pressure areas. They are also a means to document Nursing interventions which are implemented to achieve this.

http://www.wales.nhs.uk/sitesplus/863/page/65480