The integument (of skin provides several important functions, namely protection from external environmental influences, thermoregulation, electrolyte balance and sensation – pain, touch, heat and cold. The skin comprises three major layers – the dermis, the epidermis and the subcutaneous fatty layer (containing the major nerves and blood vessels). As we age, the layers of the skin and the junction between the epidermis and dermis become thin and flatten and …show more content…
These include irritant reactions to stoma appliances and other dressing adhesives; generalized rashes from latex allergies; blisters (or bullae) due to dressing adhesives or fixation tapes; eczema associated with dermatitis and venous stasis disease; hyperkeratosis (thick scaly skin) often seen in patients with lymphoedema or venous stasis disease; paper thin skin and purpura due to long term steroid therapy; dehydrated skin due to acute illness or nutritional compromise generally; and excoriated skin conditions from prolonged exposure to moisture, urine and facial or acidic effluent from enterocutaneous fistulae. Such conditions place the individual at a high risk for compromised skin integrity and subsequent infection making assessment all the more important.
Skin integrity assessment
To identify patients at risk for skin failure, assessment should be conducted on admission to the ward to identify any issues with the skin’s integrity such as existing wounds (especially pressure injuries) or vulnerable pressure points, excoriation and rashes. Information gathered from the skin inspection and aspects of management should be clearly documented in the patient’s notes and care plan. Inspection should include assessment of the skin’s color, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.
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