Introduction Nursing measures are one of the core test points of basic nursing in the Nurse Qualification Certificate Examination. They have a certain proportion of scores in the nurse examinations over the years. It can be said that nursing measures are the most important part of nurses’ clinical work. Standards and nursing basis, in order to help candidates preparing for the exam to successfully pass the 2020 Nurse Qualification Examination, the following are the common nursing problems and measures compiled by the editor. What are the nursing measures for damaged skin (_degree pressure sores)? Let’s take a look Go!
Definition
The individual's skin has been damaged.
Basics
1. Epidermal damage: abrasions, scratches. Ⅰ° pressure sores, burns, scalds, and frostbite.
2. Full-thickness skin damage: II° pressure sores, burns, scalds, and frostbite.
Related factors
1. Related to injury (trauma, burns, scalds, frostbite).
2. It is related to local continuous compression (paraplegia, traction, immobilization, long-term bed rest) (if it can be written as related to long-term bed rest).
3. Related to fragile skin (elderly people, new skin).
4. Related to skin malnutrition (thrombosis, varicose veins, diabetes).
5. Related to stimulation of body fluids (urine, intestinal juice, exudate, sweat) (can be directly written as related to stimulation of leaking intestinal fluid).
6. Related to skin edema.
7. Related to cachexia.
8. Related to radiotherapy.
9. Related to skin sensory disorders.
10. Related to itching.
Expected goals
1. There will be no secondary infection in the damaged skin.
2. No new skin damage occurs.
3. Healing of damaged skin.
4. Patients (family members) can recite the key points of skin lesion care.
Nursing measures
1. Assess, treat and record skin damage (area, depth, exudation, changes).
2. Explain the key points of care for skin lesions:
⑴ Ensure that the area is clean, dry, free from continuous pressure, and change dressings on time;
⑵ Exudation occurs , notify the nurse in time when there is pain;
⑶Skin lesions at joints require strict restriction of local activities.
3. Nursing measures to prevent skin damage:
⑴ Assist the patient to change positions regularly and in sequence, and massage the protruding bones;
⑵ Clothing, pants, and mattresses Keep the pad soft, flat, dry, clean and free of residue;
⑶Instruct patients and their families on the correct use of toilets and pressure relief products, such as balloons, air cushions, and sponge pads;
⑷Guidance Patient bed activity skills and formulation of bed activity plans;
⑸ Elderly patients with edema, skin sensory disorders, and skin malnutrition:
① Choose loose underwear, shoes and socks, and pure cotton products , Pay attention to changing and washing frequently;
② Add or remove clothes and quilts in a timely and appropriate manner;
③ Use neutral soap, the water temperature is about 40℃ when cleaning, and avoid rubbing, rubbing, or washing the back bone with force. Use talcum powder on the areas of sudden pressure;
④ Strictly follow the requirements for the use of hot water bottles and ice packs.
⑹ For those with itchy skin, actively use medication to relieve the itching and avoid scratching;
⑺ Explain skin self-protection methods and risk factors for skin damage to patients and their families.
The above are the nursing measures for damaged skin (_degree pressure sore) compiled by the editor today. I hope it will be helpful to everyone. Do you want to know how to memorize the test points for the 2020 Nurse Qualification Examination? Follow the editor for continuous updates.