Standardized Nursing Language

Skin Integrity: Skin Breakdown on Nine General

Kimberely S. Strickland
University of Virginia
NUCO-4430
November 16, 2010

Skin Integrity: Skin Breakdown on Nine General

Immobility, even for short periods, can lead to impaired skin integrity. Bony prominences place pressure on the skin, cutting off the circulation. With no blood flow to the area, the skin will eventually die. The most common areas [KH1] on the body for impaired skin integrity related to immobility are the head, shoulder blades, elbows, sacrum, and heels. The area between the knees is also prone to breakdown. Relieving pressure on these areas is crucial.

Skin integrity, impaired,Impaired Skin Integrity [KH2] is a common nursing diagnosis seen on Nine General, a busy medical-surgical nursing unit at Forsyth Medical Center (FMC) in Winston-Salem, North Carolina. This unit receives scores of patients from skilled nursing facilities weekly, and a majority of these patients have some degree of impaired skin integrity. Patients that arrive from home can also have impaired skin integrity. Almost all of the patients with impaired skin integrity have decreased mobility. Because of limited mobility, these patients are unable to reposition themselves properly and at regular intervals to allow blood to flow to the common areas cited above.

Learning more about how to help these patients will improve their quality of life. Educating nurses about impaired skin integrity will enable them to decrease the prevalence of this nursing diagnosis.

Skin integrity, impaired,Impaired Skin Integrity may be defined as “altered epidermis and/or dermis” (Johnson et al., 2006, p. 401). This definition may apply to redness, burns, ulcers, wounds, cuts, or scrapes. A variety of health issues affect how quickly skin integrity can become impaired. Cardiovascular issues, neurological disorders, hepatic and renal disease, diabetes mellitus, and malnutrition all have an effect on how quickly the skin’s integrity can deteriorate (Jaul, 2010). However, for the purposes of this paper, the nursing diagnosis skin integrity, impaired,Impaired Skin Integrity will relate to issues of immobility.

Perhaps the best way to define this diagnosis is to describe some of its many manifestations. The mildest form of skin integrity, impaired,Impaired Skin Integrity related to immobility may be evidenced by redness on a patient’s sacrum because he the patient has notn’t been turned in four hours, for example. A more severe form would be the peeling epidermis of the sacral area after a week of neglect. In another week, the area deepens and forms a small crater. Continued neglect would lead to an ulcer that would allow anyone to see the patient’s raw sacral bone.

Wound assessment is described by several parameters:
· Site
· Staging (Depth)
· Surface Appearance (Color)
· Infection
· Odor
· Exudate
· Pain
· Undermining of the soft tissue
· Condition of the surrounding skin (Jaul, 2010)

The major risk factors for the nursing diagnosis skin integrity, impairedImpaired Skin Integrity, related to immobility are decreased level of consciousness, limited mobility, impaired senses, and incontinence (Jaul, 2010). Other factors also put the patient at risk: edema, dehydration, poor nutrition, certain medications, immunosuppression, and decreased oxygenation (Jaul, 2010). The identification of a patient’s risk factors on admission is crucial to ensuring the best outcome (Senturan et al., 2009). The Norton and Braden scales are two devices used to assess this risk but neither account for oxygenation or perfusion (Senturan et al., 2009). The Braden scale is used daily in shift assessments on Nine General and when transferring patients between units or to a skilled nursing facility.

Pressure management, “minimizing pressure to body parts”, is an important intervention whichintervention, which can be utilized by the nurse to preserve a patient’s skin integrity (Bulechek, Butcher, & Dochterman, 2008, p. 585[KH3] ). To be successful, the nurse should do the following:
· Dress patient in nonrestrictive clothing
· Place on appropriate therapeutic mattress / bed
· Refrain from applying pressure to the affected body part
· Turn the immobilized patient at least every 2 hours, according to a specific schedule
· Facilitate small shifts of body weight
· Monitor patient’s mobility and activity
· Use an established risk assessment tool to monitor patient’s risk factors (e.g., Braden scale)
· Make bed with toe pleats
· Apply heel protectors, as appropriate
· Monitor the patient’s nutritional status
· Monitor for sources of pressure and friction (Bulechek et al., 2008, p. 585)
All of the above are utilized on Nine General to increase improve patient outcomes[KH4] .

A closely-relatedclosely related intervention that can be utilized by the nurse is pressure ulcer prevention (Bulechek et al., 2008). This intervention is preventative and lists steps to maintain skin integrity. For example, the nurse should:
· Document skin status on admission and daily
· Document weight and shifts in weight
· Monitor any reddened areas closely
· Remove excessive moisture on the skin resulting from perspiration, wound drainage, and fecal or urinary incontinence
· Keep bed linens clean, dry, and wrinkle-free
· Moisturize dry, unbroken skin
· Monitor for sources of pressure and friction
· Avoid “donut” devices to sacral area
· Use devices on the bed to protect the individual (Bulechek et al., 2008, p. 587)., Butcher, & Dochterman, 2008)
Again, all[KH5] of the above are utilized on Nine General as preventative methods. Pressure management and pressure ulcer prevention are two closely-relatedclosely related interventions that are used concurrently to prevent impaired skin integrity. Many of the steps found listed with one intervention are also found onlisted with the other.

FMC[KH6] also provides a skin care kit that can be utilized by the nurses at their discretion. The three-part kit must be obtained on a medication override.[KH7] It contains a skin cleanser, a moisturizer, and a protective gel. This kit is used many times daily on this unit. Any time a certified nursing assistant (CNA) or nurse views an appropriate skin impairment on a patient, the nurse will obtain the kit.

Immobility also affects a patient’s ability to eliminate wastes. If a patient is incontinent, prevention of skin breakdown becomes more difficult. Urinary and fecal incontinence both put moisture and bacteria against the skin (Beldon, 2008). This creates the perfect environment for compromising skin integrity. The moisture combines with the bacteria and enzymes in the excrement to strip away the epidermis, thus leaving a distinctive lesion that appears raw and reddened around the peri-anal area (Beldon, 2008).

Nurses at FMC have a great deal of autonomy where skin care is concerned. Part of FMC’s standards of care and practice plan for the prevention of skin impairment and altered skin integrity includes routine skin care orders. At her the nurse’s discretion, the nurse may order the care that she/he believes the patient needs without the physician’s approval. She The nurse completes the pre-printed order sheet provided by the facility and scans it to the pharmacy.[KH8] The order sheet addresses issues such as incontinence care, skin tears, redness, partial thickness ulcers, and deep wounds (Forsyth Medical Center, 2008).

Jaul proposes that decreased mobility leads to many complications and treatment should be started early and quickly to prevent problems (2010). Guidelines for repositioning are:
· Recumbent patients should be repositioned a minimum of every two hours
· Seated patients should be repositioned every fifteen to thirty minutes (Jaul, 2010, p. ?)
Frequent repositioning is the primary means of avoiding impaired skin integrity (Jaul, 2010). This relieves the pressure on bony prominences and allows blood to flow to the area. Pressure-reduction products, such as heel and elbow protectors, are also effective methods of maintaining skin integrity and relieving pressure (Walsh & Plonczynski, 2007). However, the nurse must remember that these devices alone are not sufficient to maintain skin integrity and must be used as part of a plan of care (Padula, Osbourne, & Williams, 2008).

At FMC, all patients are screened on admission using the Braden scale. At-risk patients are identified. Mobility issues are considered and proper measures are implemented to decrease the risk of skin impairment. These patients are repositioned frequently. FMC policy follows Jaul’s recommendations of every two hours for recumbent patients and every fifteen to thirty minutes for seated patients (Jaul, 2010).[KH9] Nurses and CNAs also make frequent use of the skin care kits. Generally, heel and elbow protectors are not used. Instead, arms and legs are propped with pillows and rolled towels in such a way to avoid pressure to those areas. AlsoIn addition, a pillow is placed between the patient’s knees to avoid pressure in this area.

The use of pillows and linens to relieve pressure is very effective. Many patients are able to move to some degree so these the patient much be checked frequently to ensure that the props remainy are in place. The skin care kits are very effective at protecting the patients’ skin integrity. The cleanser is very gentle and rarely causes any irritation. The moisturizer and protective gel are often mixed and massaged into the patients’ skin to stimulate blood flow while moisturizing and protecting the patients’ largest organs. Not only do the patients enjoy these mini massages, but they also comment on how much better the area feels after the application[KH10] .

FMC policy is conducive to excellent patient skin care. Because every patient receives a skin assessment by a registered nurse on admission, no issues of impaired skin integrity go unnoticed. Because of the autonomy the facility grants to the nurses, they can order what is needed without having to wait on for the physician’s specific order to do so. The nurse’s orders are quickly and aggressively implemented, as recommended by Padula et al , Osbourne, and Williams (2008).

The only outcome relevant [KH11] [KH12] to the selected nursing diagnosis as it relates to mobility issues is Tissue Integrity: Skin and Mucous Membranes (1101). The definition is “structural intactness and normal physiological function of skin” (Moorhead, Johnson, Maas, & Swanson, 2008, p. 699). The rating scale for the indicators is below[KH13] :
· 1 Severely Compromised / severe
· 2 Substantially Compromised / substantial
· 3 Moderately Compromised / Moderate
· 4 Mildly Compromised / Mild
· 5 Not Compromised / None (Moorhead et al., 2008, p. 699)

The outcome indicators and definitions are listed below:
· Skin temperature (110101): The skin should feel lukewarm to the touch. Skin that is too hot is abnormal.
· Sensation (110102): The patient should feel your touch on his skin.
· Elasticity (110103): When pulled away from the body, skin should return to its normal position. Skin elasticity decreases as people age.
· Hydration (110104): Moisturize the skin with appropriate lotions and skin care products.
· Perspiration (110104): Wetness helps to create an ideal environment for impairing skin integrity. If the patient is perspiring, adjust the room temperature or the number of blankets until the environment is comfortable and perspiration is no longer a problem.
· Texture (110108): The texture of the patient’s skin is noted on the initial assessment. Is the skin thin, dry, peeling, or red? These factors can contribute to impaired skin integrity.
· Tissue perfusion (110111): Ensure that the peripheral pulses are strong and equal. Assess the capillary refill.
· Skin integrity (110113): Assess the patient for any open areas.
· Erythema (110121): Skin redness may be an early indicator of pressure issues.
· Necrosis (110123): Premature skin death occurs when pressure has eliminated the blood supply to an area for an extended length of time (Moorhead et al., 2008, p. 699).
The above indicators are utilized daily on Nine General as a means of measuring how the patients are responding to the nursing interventions. They are included in the plan of care by the initiating nurse as a means of communicating with subsequent nurses. This will ensure continuity of care for the patient and increase the chance for a better outcome. All of the outcomes are not placed on one care plan at one time but are chosen for each patient based on his assessment and situation. Individualizing the plan of care also ensures that the patient will receive the most appropriate care possible.

With an aging population suffering from health issues that deteriorate mobility, the nursing diagnosis of Impaired Skin Integrity deserves much attention. Impaired skin integrity can lead to complications of ulcers, infection, sepsis, and ultimately death[KH14] . By using simple devices and linens on the unit, pressure can be decreased or eliminated on bony prominences and blood flow to high-risk areas can be maintained in a manner that does not put the patients’ skin integrity at risk.

Staff[KH15] on Nine General will receive education and in-service training about how to care for patients with impaired skin integrity. The education will include photos and explanations about interventions that can be implemented to improve outcomes for their patients. Staff will also be reminded about the facility’s policy regarding repositioning. Currently, a patient care representative is[KH16] making rounds on the unit to ensure that staff members perform their duties in a manner that is satisfying to the patient while complying with facility policy. During this re-training, repositioning and skin care will be added to this check listchecklist to ensure that patient care standards are being maintained. Staff will be encouraged to ask questions or offer suggestions to improve care. Patients who are capable will also be made active participants. They will be educated about maintaining skin integrity and repositioning guidelines. They will be instructed to call for help when turning or repositioning. Additionally, staff will be encouraged to remain alert to new situations that may be used to help staff better understandbetter understand how to improve current methods to maintain and/or improve their patients’ skin integrity. These situations will then be used in ongoing education for stafffor staff so that they may deliver the best possible care for their patients.


References

Beldon, P. (2008). Problems encountered managing pressure ulceration of the sacrum. British Journal of Community Nursing, 13(12), 6-12.

Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.

Forsyth Medical Center (2008, May). Standards of care and practice: Prevention of skin impairment/altered skin integrity. Retrieved November 1, 2010, from employee intranet[KH17]

Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: current strategies. Drugs & Aging, 27(4), 311-325.

Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC Linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.

Padula, C. A., Osbourne, E., & Williams, J. (2008). Prevention and early detection of pressure ulcers in hospitalized patients. Journal of Wound, Ostomy and Continence Nursing, 35(1), 66-75.

Senturan, L., Karabacak, U., Ozdilek, S., Alpar, S. E., Bayrak, S., Yuceer, S., & Yoldz, N. (2009). The relationship among pressure ulcers, oxygenation, and perfusion in mechanically ventilated patients in an intensive care unit. Journal of Wound and Ostomy Care, 35(5), 503-508.

Walsh, J. S., & Plonczynski, D. J. (2007). Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers. Journal of Wound, Ostomy, & Continence Nursing, 34(2), 178-183.





Criteria for Grading Formal Paper on Standardized Nursing Language
25/25 Descriptions of diagnosis (definition, characteristics, etc). Description of intervention and analysis of nursing activities listed in the text
Dx is from NANDA list and defined. For defining characteristics you shared two extremes of mild and that associated with severe neglect. You nicely described how the dx applies to your population. You defined the nursing intervention and included a second intervention. And yes, while they are similar, your focus would have been better on one to allow you the depth to then analyze the literature. You share well your reasons for selecting this intervention. You also described, defined and summarized the activities listed in the intervention (NIC text) that were specific to your patients.

22/25 Use of & analysis of current literature about intervention
Your intervention was Pressure Management. Your paper and your analysis should be entirely focused on this, pressure management. From your review of the literature, are there new activities that need to be evaluated for inclusion in Bulechek? Are there activities that should be eliminated? What is the current literature on the beds that are being used? What you did with Braden was perfect … you critiqued it for what was missing. That’s the analysis that you want!! Are there better scales? This skin care kit, you need to ask yourself, is this evidence based? If not, that may be in your conclusion as to what you could do; can you do a research study to prove that the gel is effective? You did do a nice job of relating what you read to your practice. You brought it in throughout. You did a good job of noting how your policy is consistent with Bulechek and implying that your policy makes the nurses stay on top of the quality of care. What I want you to work toward is that focused analysis to bring it altogether for your reader. You don’t want the reader to have to work.

25 / 25 Description & analysis of outcome(s)
You did a better job of getting the ONE outcome you wanted and your explanation of why you chose only one was perfect. Careful with not using the scales verbatim per the authors. Semantics is the issue here and the reason why they used two scales.

9 /10 Summary and Conclusions
You spoke well about what is going on with your unit specific to this intervention. Is there more that can be done beyond your unit that you can work toward? My concern was more with the writing. See below.

12 /15 Quality of writing, use of correct format (APA).
APA basics well done! You really got that down pat, except for one very important piece. You are quoting from these sources and you need page numbers associated with the definition and the lists that you include. Think of your lists as those long quotes that are indented. Writing … I believe it can be cleaner and stronger. You used your journals to discuss the activities, but you need to tie it all together. You need to keep the focus entirely on the one intervention you chose, the focus of your paper. Doing so, you need to refer to it often. Also, try to branch out to more journals. There were times that you needed supportive citations and they weren’t there.

Grade: 93 Overall, a very good paper. Well done.

[KH1]Source is important – you need a citation.

[KH2]Remember from class, when you use it as the nursing diagnosis, each word is capitalized (see SNL PowerPoint on Collab)

[KH3]You must use quotes and give the page numbers, otherwise, it’s plagiarism.

[KH4]Somehow you need to acknowledge that these are 11 of the 18 activities presented by Bulechek et al.

[KH5]See comment above.

[KH6]APA – do not begin sentences with abbreviations.

[KH7]Important?

[KH8]Importance?

[KH9]Good!

[KH10]Is this measure evidence based practice?

[KH11]Excellent – you explained well why you chose the outcome you did and you explained it in one sentence!!

[KH12]Did you use Johnson to decide which outcome to use?

[KH13]There are two scales used for these indicators, not just this one. While they are very much alike, both need to be included.

[KH14]You again need a source

[KH15]Need a transition sentence to this. It’s exactly what you need to be writing, but you need to transition your reader to this change in thought. The change to “will” and future tense needs to be revisited with this transition.

[KH16]Currently is vs. will make the paragraph confusing.

[KH17]Check Perrin