The Integument
The moving and turning just referred to are directly related to the maintenance of skin integrity. Ordinarily, as a person sleeps or rests in bed, he turns and moves, changing position and avoiding pressure on any one area for very long. This shifting about occurs frequently even during sleep. The movement preserves the integument from assault that might deprive skin areas of an adequate blood supply over a period of time and thus break down.
Persons who are aged, paralyzed, obese, or immobilized because of disability are all prone to skin breakdown. Either sensation is not keen enough to warn of pressure, or there is lack of ability to turn without aid because of weight, weakness, or the pressure of restrictive mechanical devices. If no assistance is given to provide mobility, the skin suffers in two ways: (1) muscle disuse decreases the circulatory exchanges in the soft tissues and (2) the constant pressure obstructs the flow of blood to the part. Ischemia, or local anemia of the area, develops, and this leads to necrosis and ulceration. This is the classic decubitus ulcer that is so insidious in its onset and so difficult to heal. In addition to the threat of skin breakdown due to immobility per se, there is the danger of malnutrition in the bedfast patient because he is in negative nitrogen balance. Unless the skin pressure and embarrassment of its blood supply, a fact thet emphasizes the interrelationship of the body`s functional areas.
Nursing intervention is the primary preventive therapy in this area. Skin breakdown can and must be prevented through nursing, not medical, care. The development of an open area caused by pressure is unnecessary today. The responsibility for initiating prophylactic measures rests with you. In addition to frequent position changes, gentle message over bony prominences, range-of-motion exercises, and mechanical aids may be used. An alternating-pressure mattress, a flotation mattress with its gel foam pad that protects the sacral area, oscillating beds, tilt boards, or even a simple measure such as a sheepskin under the hips can be used to protect the skin.
Position change must be accompanied by close inspection and meticulous care of the skin. The patient`s linen should de dry and wrinkle-free at all times. Keep the skin clean and use an emollient lotion to keep it pliant. Make sure the lotion you use is thoroughly absorbed, or the excess removed, to prevent maceration of skin by too much moisture.
In essence, prevention ensures an intact musculoskeletal system in the immobile patient. Provide as much movement as possible. Use anatomical positioning that avoids pressure points for long periods. Encourage the patient to participate in his care. Use patient teaching for optimum nutrition. And base your intervention on careful assessments of skin and muscle tone so that the direction of adaptation will be toward full function.
References :
Wessels, Norman K., “How Living Cells Change Shape”, Scientific American, 225: No. 4, 1971.
Browse, N.L., Physiology and Pathology of Bedrest. Springfield, III.: Charles C. Thomas, Publisher, 1965.
Olson, Edith V., “The Hazards of Immobility”, American Journal of Nursing, 67: No.4, 1971.
Murray, RB and Zentner JP., Nursing Concepts for Health Promotion, Second Edtion, Prentice-Hall, Inc, Englewood Cliffs, N.J, 1979.
