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Understand nurse aide
skills needed to promote
skin integrity.
Unit B
Resident Care Skills
Essential Standard NA5.00
Understand nurse aide’s role in providing residents’ hygiene, grooming, and skin care.
Indicator 5.02
Understand nurse aide skills needed to promote skin integrity.
15.02 Nursing Fundamentals 7243
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25.02 Nursing Fundamentals 7243
As a direct care giver, the nurse aide will be the key team member in the prevention of pressure ulcers.
5.02 Introduction
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PRESSURE ULCERS
AKA:
Bedsores
Decubitus Ulcers
5.02
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PRESSURE ULCERS
Caused by pressure on area of skin that interferes with circulation
5.02
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BRAIN STORM
5
Think
What does circulation
provide for tissues?ActRaise your hand and share your thoughts!
Wait to be called on.
Nursing Fundamentals 72435.02
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PRESSURE ULCERS
Occur where bones come close to the skin surface or bony prominences.
5.02
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PRESSURE ULCERS
–toes, heels, ankles, knees
–hips, elbows, shoulders
–spine (especially tailbone area)
–ears, cheeks, collarbone area
–back of head
5.02
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PRESSURE ULCERS
Can develop where areas of body rub together and moisture collects, especially in obese residents
5.02
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PRESSURE ULCERS
–Under breasts
–Between folds of abdomen
–Between crease of buttocks
–Between thighs
5.02
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PRESSURE ULCERS
1 OUNCE
PREVENTION
1 POUND
CURE
5.02
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PRESSURE ULCER
PREVENTION
Keep skin clean and
dry!5.02
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PRESSURE ULCER
PREVENTION
Keep linen dry and free of wrinkles and objects that cause pressure to the skin!
5.02
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PRESSURE ULCER
PREVENTION
Clean urineand fecesfrom skin as soon as possible!5.02
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PRESSURE ULCER
PREVENTION
Repositionresidents at least every two hours!
5.02
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PRESSURE ULCER
PREVENTION
Make sure clothing and shoes do not bind or constrict!
5.02
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PRESSURE ULCER
PREVENTION
Pat skin dry when bathing; never scrub.
5.02
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PRESSURE ULCER
PREVENTION
Encourage adequate nutritionand fluids!
5.02
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PRESSURE ULCER
PREVENTION
Massage
healthy skin
and tissue
around the
area.5.02
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PRESSURE ULCER
PREVENTION
Massage skin often.
Use light circular stroke
to increase circulation.
5.02
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PRESSURE ULCER
PREVENTION
Use little
or no
pressure
on bony
areas.5.02
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PRESSURE ULCER
PREVENTION
Do NOT
massage a
white, red, or
purple area or
put any
pressure on it. 5.02
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PRESSURE ULCER
PREVENTION
Be careful during
transfers. Avoid pulling or
tearing fragile skin.
5.02
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PRESSURE ULCER
PREVENTION
Take YOUR jewelry off!
This is just
like a
knife!
5.02
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PRESSURE ULCER
PREVENTION
Keep YOUR nails short!
This is just
like a
knife!
5.02
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PRESSURE ULCER
PREVENTION
Keep YOUR nails short!
This is
safe.
5.02
Page 26
26
IMMEDIATELY
ANY CHANGE IN
SKIN CONDITION!
5.02 Nursing Fundamentals 7243
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Nursing Fundamentals 7243 27
PRESSURE ULCER
PREVENTIVE DEVICES
Bed cradle
Heel and elbow protectors
Flotation pads or cushions
Pillows
Water beds
Alternating pressure mattresses
Eggcrate mattresses
5.02
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage One - red, darkened or non-blanchable skin, which is still present 30 minutes after pressure relieved
5.02
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage One position off area and report; do not massage
observe every 2 hours and report changes to supervisor
5.02
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Stage 1 pressure ulcer
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage Two - addition of blister-like lesions; skin may be broken
5.02
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage Two • position off area at all times,
• report need for dressing changes
• report odor, drainage, any change in size
5.02
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Stage 2 pressure ulcer
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage Three - skin tissue is
destroyed and fatty tissue
may be involved; infection
and eschar (scab) may
result
5.02
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage Three
continue prevention practices
report any changes in area
5.02
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Stage 3 pressure ulcer
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage Four - skin, fatty tissue destroyed and muscle and bone involved!
5.02
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
Stage Four
report any signs of systemic infection, including but not limited to:
• wound odor• pain• elevated temperature with confusion
5.02
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Stage 4 pressure ulcer
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equipment• Elbow pads
• Heel booties
• Bed cradle
• Footboard
• Pressure relieving mattress
• Specialty beds
– Airflow
– Alternating pressure
– Wedge turning
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Nursing Fundamentals 7243 41
POSITIONING
5.02
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F Y I - Intentional Repeat
There is intentional repeat of some HSII course content in Nursing Fundamentals.
Repeating course content distributes learning over time and increases long term memory.
Academic and skill competence must be maintained at a very high level for direct resident care.
42Nursing Fundamentals 72435.02
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POSITIONING
Purposes:• Assist with examinations
• Assist with procedures
• Prevent pressure on skin
for prolonged periods of
time
5.02
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POSITIONS
Dorsal recumbent positionflat on backknees slightly separated and flexedfeet flat on bed
http://www.wisc-online.com/objects/ViewObject.aspx?ID=MEA1604
5.02
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POSITIONS
Horizontal recumbent position –supine
flat on backlegs slightly separated and extended
http://www.wisc-online.com/objects/ViewObject.aspx?ID=MEA1604
5.02
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POSITIONS
Prone position
flat on abdomen with head turned
to side
arms at sides or flexed on either
side of head
http://www.wisc-
online.com/objects/ViewObject.aspx?ID=M
EA1604
5.02
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POSITIONS
Side lying position
positioned on either side
head in straight line with spine
pillows used to support head,
back, arm, and leg
http://www.wisc-
online.com/objects/ViewObject.aspx?ID=MEA1604
5.02
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POSITIONS
Lateral position
positioned on either side
bottom arm extended behind back,
top arm flexed in front of body
top leg slightly flexed
http://www.wisc-
online.com/objects/ViewObject.aspx?ID=MEA1604
5.02
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POSITIONS
30 Lateral Reclined Position
hips rotated 30 degrees
pillow between knees
pillow under arm for comfort and
to relieve pressure on elbow
pressure relieved from sacrum and http://www.wisc-
online.com/objects/ViewObject.aspx?ID=MEA1604
hip 5.02
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POSITIONS
Fowler’s position
sitting position in bed with head
elevated at 45-60 degree angle.
knees slightly flexed
position causes pressure on
sacrum and buttockshttp://www.wisc-
online.com/objects/ViewObject.aspx?ID=MEA1604
5.02
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POSITIONS
Sim's position
positioned on LEFT side
left arm extended behind body
right arm flexed in front of body
right leg flexed toward abdomen
used for enema administrationhttp://www.wisc-
online.com/objects/ViewObject.aspx?ID=MEA1604
5.02
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POSITIONS
Sim's position
Best position for enemas
5.02
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TURNING POSITIONING
LIFTING MOVING
5.02
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Moving, Turning, Positioning
And Lifting
Good body mechanics necessary
Prevents injury to resident
Protects nurse aide from
injury
Good body alignment
Promotes comfort for
resident
5.02
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Moving, Turning, Positioning
And Lifting
Safety major considerations
Get help if needed
Receive directions from
supervisor regarding any
restrictions for
positioning or movement
5.02
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Moving, Turning, Positioning
And Lifting
Safety major considerations
Protect and secure any special
equipment being used by the
resident prior to movement
(e.g., drainage tubes).
Elevate bed to comfortable
working level
5.02
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Moving, Turning, Positioning
And Lifting
Safety major considerations
Protect skin from friction
roll when possible
lift with assistance
prevent sliding
use turning sheet
5.02
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Moving, Turning, Positioning
And Lifting
Use postural supports as directed:
Rolled blankets
Pillows
Rolled towels
Footboards
Bed cradles
5.02
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Moving, Turning, Positioning
And Lifting
Reposition at least every two hours or as directed Eliminates pressure on bony
areas Provides comfort Exercises muscles Moves joints Stimulates circulation
5.02
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Moving, Turning, Positioning
And Lifting
Coordinate lifting and moving Move on a certain count,
usually count of three Gain cooperation of resident Have residents help
themselves as much as possible
5.02
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Moving, Turning, Positioning
And Lifting
Coordinate lifting and moving (continued)
Use transfer belt (gait belt) when appropriate
When in doubt, always ask for assistance from co-workers
5.02
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SKILL 5.02AMoving Resident Up in Bed
with/without Turn Sheet
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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SKILL 5.02B
Positioning Resident on Side
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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Repositioning Resident In Chair
Or Wheelchair
5.02
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Repositioning Resident In Chair
Or Wheelchair
Reasons for changing position
every two hours or as directed
Promotes comfort
Reduces pressure
Increases circulation
Exercises joints
Promotes muscle tone
5.02
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Repositioning Resident In Chair
Or Wheelchair
Body kept in good alignment with
head in straight line with spine
Plastic or vinyl surface of chair
covered, with use of pressure-
relieving cushion preferred
Pillows or soft blankets used for
support
5.02
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Repositioning Resident In Chair
Or Wheelchair
Feet REST
on floor or
footrest of
wheelchair
5.02
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Repositioning Resident In Chair
Or Wheelchair
Hips
positioned
well back
in chair
5.02
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Repositioning Resident In Chair
Or Wheelchair
Weight shifting
utilized in between
repositioning
5.02
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BRAIN STORM
70
Think
Why shift weight?ActRaise your hand and share your thoughts!
Wait to be called on.
Nursing Fundamentals 72435.02
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Other Nurse Aide Skills that Promote Skin Integrity
http://www.webmd.com/skin-problems-and-treatments/slideshow-common-adult-skin-problems
Applying Non-Sterile DressingApplying Warm and Cold Therapy
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• Covering applied to wound or injured body part where slight risk of infection or re-injury
• Materials come in various types and sizes:
–Gauze pads
–Band-aids
–Thick compresses
APPLYING NON-STERILE DRESSINGS
5.02
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Related
SKILL
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SKILL 5.02CApply Non-Sterile Dressing
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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• Requires
physician’s order
for type of therapy
and length of time
for application
WARM AND COLD THERAPY
5.02
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• Purposes and Effects
–WARMTH: dilates blood vessels
• increased blood supply to area
•blood brings oxygen & nutrients for healing
• fluids are absorbed
•muscles relax
•pain relieved
WARM AND COLD THERAPY
5.02
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• Purposes and Effects
–COLD: constricts blood vessels
• decreased blood supply to area
• prevents swelling
• controls bleeding
• numbs skin, reducing pain
• reduces body temperature
WARM AND COLD THERAPY
5.02
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• Dry cold - water does not touch
skin
–ice bags
–ice caps
–ice collars
–disposable cold pack
TYPES OF WARM AND COLD THERAPY
5.02
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• Moist cold - water
touches skin
–compresses – localized
application
–soaks - body part
immersed in water
–cool sponge bath
TYPES OF WARM AND COLD THERAPY
5.02
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• Dry warmth – pads
with circulating
warm water
• Moist warmth
–compresses
–soaks
–sitz bath
TYPES OF WARM AND COLD THERAPY
5.02
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–Use bath thermometer to measure the temperature of moist heat solutions.
–Do not operate equipment you have not been trained to use.
–Temperature never over 105° F. Check skin frequently and report any signs of complications.
GUIDELINES FOR WARM THERAPY
5.02
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–Apply ice caps with metal or plastic lids away from skin
–Cover ice caps/bags/collars prior to application
–Check skin frequently and report any signs of complications
–Never leave in place longer than directed by supervisor
GUIDELINES FOR COLD THERAPY
5.02
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Related
SKILL
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SKILL 5.02D
Apply Warm and Cold Applications
Training Lab AssignmentEngage in the Skill Acquisition Process for:
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The Bottom Line
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Skin is the body’s first line of
defense against disease.
Maintain the integrity of the
skin.
Page 86
Understand nurse aide’s role in
promoting skin integrity.
86
END
5.02
5.02 Nursing Fundamentals 7243