Page 129 - ACCCN's Critical Care Nursing

106 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

TABLE 6.1 Principles of practice TABLE 6.2 Skin and tissue assessment

Reducing risks to patients Provision of quality care Factor Observations
● Recognition of the specific ● Development of knowledge Colour of the skin ● Jaundice, erythema, pallor, cyanosis
needs of critically ill patients, and skills for practice
particularly those who are ● Evidence based practice Condition of the skin ● Skin turgor (elasticity): evidence of
unconscious, sedated or ● Optimal use of protocol- oedema (taut skin), dehydration
immobile driven therapy (dryness, tenting of the skin),
● Recognition of specific ● Competent, efficient and age-related or steroid-related
complications that may safe practice damage (thin, papery, easily torn
require special observation ● Selection and application of skin), skin tears
or treatment appropriate nursing ● Presence of: rash, cellulitis, irritation,
● Vigilant monitoring and early interventions bruising, swelling
recognition of signs of ● Monitoring the Tissue perfusion ● Hypoperfusion: capillary refill time,
deterioration consequences of nursing cool extremities, pulse strength and
● Selection, implementation interventions volume, blanching of the skin
and evaluation of specific ● Review and evaluation of ● Hyperaemia: very warm, red areas of
preventive measures nursing practices skin
● Management of potentially ● Continuity of care ● Thrombus formation: warm, red,
detrimental environmental ● Effective critical care team swollen areas (especially calves)
factors that may affect the functioning
patient Moisture ● Excessive sweating
● Skin damage caused by moisture,
especially: skinfolds, under the
breasts, in the groin, between the
buttocks
want and second, the nurse’s professional assessment of Wounds, drains, ● Evidence of inflammation, infection,
what is required. As with all aspects of care, the patient cannulae, catheters pressure damage, skin excoriation
has the right to refuse personal hygiene measures. Many caused by leaking exudates, correct
positioning of drains, need to redress
critical care patients are unable to participate in decision wounds
making, and in these cases it falls to the nurse at the
bedside to determine what level of care is necessary.
Washing patients provides opportunities for the nurse to
assess the patient’s skin and tissue. Often this enables the completing personal hygiene and interruptions that affect
nurse to: pick up vital clues about the patient’s health the dignity of the patient. Privacy for the patient during
status; identify tissue damage that requires treatment; and personal hygiene should be of paramount concern.
identify dressings or wounds that require attention. There The length of time taken to wash a patient and the envi-
are a number of areas to consider when assessing the skin ronmental temperature are factors that affect cooling.
(see Table 6.2). Excessive moisture on the patient’s skin Water on exposed skin causes rapid heat loss through
from sweat can be problematic, particularly in skinfolds. conduction, convection and radiation, and for many
Perspiration is a normal insensible loss, and is invisible. years tepid sponging was used in critical care as a method
Body sweat is usually related to temperature and is of cooling pyrexic patients. Vasoconstriction increases
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observed on all skin surfaces, especially the forehead, the patient’s perception of cold and the possibility of
axillae and groins. Emotional sweating is stress-related shivering, which can affect the patient’s cardiovascular
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and is observed on the palms of the hands, soles of the stability. When shivering occurs, vulnerable patients, with
feet, forehead and axillae. low energy reserves, can rapidly use energy to keep warm.
The higher oxygen consumption associated with shiver-
BASIC HYGIENE ing may be particularly significant in elderly patients. 4
A daily bed-bath with intermittent washes of the face and A range of cleansing solutions is available for washing.
hands is standard care, however patients who are sweat- Although soap is effective in facilitating the removal of
ing, incontinent, bleeding or with leaking wounds should bacteria, it can cause dryness of the skin. Aqueous cream,
be washed and their linen changed as often as necessary. which can be used as a soap substitute, or emulsifying
Wet, creased sheets may cause pressure on dependent ointments are preferable, as they have moisturising pro-
areas, increasing the risk of pressure ulcer development. perties, although the latter is greasier. Topical emollients
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For many critically ill patients, being moved is painful (moisturisers) either trap water or draw water into the
and it may be appropriate to give prophylactic pain relief dermis, and help to protect damaged skin by creating a
before commencing a bed-bath.
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waterproof barrier. Baby care products are often used,
The timing of a bed-bath and personal hygiene is impor- although these may be the least effective due to their low
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tant. When several nurses are required to move the oil content. Specific topical treatments may be required
patient, it makes sense to consult with colleagues to coor- for patients with skin diseases such as dermatitis. Dispos-
dinate their availability. Planning ahead with respect to able cloths should be used for washing, as linen flannels
events such as medical rounds, chest X-ray requirements have been shown to harbour bacteria. Complete dispos-
and family visits helps avoid unnecessary delays in able wash kits are available with potential advantages of