Unit 3 Hygiene and Tissue Integrity

Functional Ability

• Definition: Refers to the physical and cognitive capacities that enable a person to perform daily activities independently and effectively. It encompasses not only the capacity to execute tasks but also the decision-making abilities that influence these actions.

• Key Factors Affecting Functional Ability:

  • Physical Abilities: Include mobility, strength, coordination, and endurance, which are essential for activities such as walking, standing, and performing activities of daily living (ADLs).

  • Cognitive Abilities: Involve memory, attention, and problem-solving skills, all of which are critical for making decisions regarding one's care and daily routines.

  • Sensory Functions: Such as vision and hearing, play a significant role in functional ability; impaired sensory perception can hinder a person's ability to respond to their environment effectively.

Functional Assessment

• Purpose:

  • To evaluate how illness impacts self-care ability and to determine potential barriers to independence.

  • To ascertain the level of assistance the patient requires in various activities, facilitating appropriate care planning.

  • To monitor changes in functional ability over time, especially for patients with chronic health issues, to detect deterioration or improvement in their condition.

Risk Factors for Pressure Injury Development

• Major Risk Factors:

  • Impaired Sensory Perception: Delayed response to pressure can lead to skin breakdown.

  • Impaired Mobility: Limited ability to reposition oneself increases risk of pressure injuries.

  • Alterations in Level of Consciousness (LOC): Patients with reduced awareness may not react to discomfort.

  • Shear and Friction: Often result from sliding down in bed or chairs, exacerbating skin breakdown.

  • Moisture: Excessive moisture from sweating or incontinence can compromise skin integrity.

Sensory Perception

• Importance: The ability to feel pressure-related discomfort is crucial for preventing pressure injuries, as it alerts individuals to reposition and alleviate pressure points.

• Braden Scale for Predicting Pressure Sore Risk:

  • 1: Completely limited response - Total unawareness of pressure sores risk.

  • 2: Very limited response - Responds only to severe pressure.

  • 3: Slightly limited - Has some ability to feel but requires regular monitoring to ensure safety.

  • 4: No impairment - Fully responds to discomfort and assists in prevention efforts.

Moisture and Activity

• Moisture Ratings:

  • 1: Constantly moist - Continual surface moisture increases risk of skin breakdown.

  • 2: Very moist - Frequently moist, requiring diligent care.

  • 3: Occasionally moist - Risk is present but manageable.

  • 4: Rarely moist - Favorable conditions for skin integrity.

• Activity Levels:

  • 1: Bedfast - Patient is confined to bed and unable to mobilize.

  • 2: Chairfast - Patient can sit in a chair but cannot walk.

  • 3: Walks occasionally - May walk short distances with assistance.

  • 4: Walks frequently - Can independently mobilize, decreasing risk of pressure injury.

Pressure Ulcers

• Risk Factors:

  • Impaired Mobility: Such as spinal cord injuries or surgeries restricting movement.

  • Impaired Sensory Perception: Patients unable to feel pressure or pain.

  • Incontinence Issues: Leads to moisture exposure, exacerbating risk.

  • Nutritional Deficits: Conditions like diabetes can affect skin integrity and healing.

  • Altered Consciousness: Conditions such as dementia reduce awareness of pressure points.

• Classification of Pressure Injuries:

  • Stage 1: Non-blanchable redness of intact skin, indicating potential damage.

  • Stage 2: Partial-thickness loss of skin, presenting as a shallow, open ulcer.

  • Stage 3: Full-thickness tissue loss potentially exposing subcutaneous tissue.

  • Stage 4: Full-thickness loss with exposed bone, tendon, or muscle, requiring advanced management and potential surgical intervention.

Wound Assessment

• Assessment Components:

  • Temperature: Assess for warmth which may indicate infection.

  • Odor: Note any foul smells that could signify necrosis or infection.

  • Location: Document the anatomical site to monitor for consistent issues.

  • Shape: Observe the shape of the wound for evaluation over time.

  • Size: Measure length, width, and depth to monitor healing progression.

  • Color of Wound and Exudate: Observing for color changes can indicate healing or infection.

  • Presence of Necrotic Tissue or Infection: Identifying dead tissue is critical for treatment planning.

• Necrotic Tissue:

  • Eschar: Represents dry, leathery tissue, indicating full-thickness skin loss.

  • Slough: Moist, loose, and stringy tissue; a sign of inflammation or infection.

Healing Process

• Partial-Thickness Wound Repair: Involves a series of healing stages: inflammation, epithelial proliferation, and migration of cells to cover the wound.

• Full-Thickness Wound Repair: Involves hemostasis, inflammatory, proliferative, and maturation phases, each critical for successful healing.

• Complications: Include hemorrhage, infection, dehiscence (wound reopening), and evisceration (protrusion of organs through the wound).

Wound Care Strategies

• Goals:

  • To prevent infection through proper sterile techniques.

  • Clean the wound regularly to remove debris and promote healing.

  • Minimize pain by employing appropriate analgesics.

  • Remove nonviable tissue through debridement to facilitate healing.

  • Maintain a moist environment optimal for wound healing, reducing scarring.

  • Control odor through appropriate drainage management and wound care products.

  • Protect surrounding skin to prevent further breakdown.

• Types of Dressings: Various types include hydrocolloid, alginate, foam, and composite films, chosen based on the wound's condition and needs.

Hygiene Practices

• Bathing Sequence:

  • Eyes -> Face -> Arms -> Chest -> Abdomen -> Legs -> Change water (repeat for Perineum, Buttocks, Back) to reduce contamination risk.

• Foot Care: Critical for patients with diabetes; inspect, wash, dry thoroughly, apply lotion to prevent cracking, and avoid nail trimming unless instructed. Report abnormalities immediately to ensure prompt care.

• Bed Bath: Ensure all necessary supplies are prepared, consider patient preferences, administer pain medication if necessary, and ensure warmth while respecting cultural practices.

Perineal Care

• Cleaning Guidelines:

  • Female: Clean from labia to anus to prevent urinary tract infections.

  • Male: Clean the penis, retract the foreskin if the patient is uncircumcised. Employ different washcloth areas for each wipe to avoid cross-contamination and ensure thorough cleaning.

Bed-Making Practices

• Importance: Change linens regularly to prevent skin breakdown, and adhere to clean techniques—never shake or place dirty linens directly on the floor to minimize contamination risk.

Delegation of Care Tasks

• UAP’s Scope of Practice: Understand the scope of duties within delegated care tasks, including ADLs like bathing, grooming, and positioning. Nurses must be aware of delegation limits to maintain patient safety and uphold care standards.