Skin Integration Disorder:Pressure Ulcer Risk Conditions

Skin Integration Disorder:Pressure Ulcer Risk Conditions

<Definition>
Skin integration disorders include mechanical factors (compression, slippage, rubbing, attachment / detachment of adhesive, etc.), chemical factors (stool, urine, exudate, etc.), infection, allergies, drug treatment, radiation therapy, aging, etc. This is a condition in which the skin is damaged and the protective defense function is disrupted.

<Nursing care plan>

Target
I can’t have a pressure ulcer
Understand pressure ulcer measures
You can try to prevent pressure ulcers

Observation plan
1. Vital signs, awareness level
2. Age and gender
3. Diseases and treatment details
4. Weight, presence or absence of weight change
5. BMI
6. General skin condition (edema, redness, exfoliation, erosion, dryness, moistness, sweating, skin temperature, tension, etc.)
7. Presence or absence of sensory neuropathy or paralysis
8. Presence or absence of mechanical irritation (compression, friction, slippage, attachment / detachment of tape)
9. Presence or absence of urinary incontinence and fecal incontinence
10. Presence or absence of infection
11. Inspection data (TP, Alb, WBC, CRP, Hb)
12. Are you using the right pressure distribution device?
13. Utilization of social support

Care plan
1. Use a body pressure distribution mattress that matches your body pressure and activity
2. Adjust the positioning to suit the patient
3. After changing the position, pull out the back and legs
4. When gatch-up the bed, raise the lower limbs by about 15 ° and then raise the head side.
5. Keep your body clean and observe your skin daily
6. If urinary incontinence persists, determine the incontinence pattern and induce urination before incontinence occurs.
7. If urinary incontinence continues, perform excretion care according to the patient’s pattern so that the excrement does not hit the skin for a long time.
8. Control defecation
9. Consider supplements to ensure high calorie intake if dietary intake is low
10. Strive to prevent joint contracture
11. Introduce available social support

Education plan
1. Explain the causes of pressure ulcers
2. Explain the areas where pressure ulcers are most likely to occur
3. Explain the postural change method and decompression method to prevent pressure ulcers
4. Explain the use of a pressure distribution mattress according to body pressure and activity
5. Introducing pressure ulcer prevention equipment necessary to prevent pressure ulcers
6. Explain that if you have urinary incontinence or fecal incontinence, remove it immediately.
7. Explain the proper diet


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