Page 130 - ACCCN's Critical Care Nursing

Essential Nursing Care of the Critically Ill Patient 107

being effective for patient’s skin cleaning without requir-
ing rinsing and therefore drying the skin, and being dis- TABLE 6.3 Treatment of skin tears
posable may reduce potential for infection and certainly
reduces linen costs. 1 Factor Interventions
Personal hygiene involves washing the patient’s hair as Cleansing ● Gently clean skin with saline or non-toxic
necessary, shaving the patient, management of cerumen wound cleaner
in ears and care of finger and toe nails. While normal ● Allow to dry or pat dry carefully
shampoo can be used, hair caps and washing products Skin flap ● Approximate the skin tear flap/tissue, if
are available that are easier to use for bed ridden patients. present, as closely as possible
Male facial hair should be managed as per the patient’s Dressing ● Provide appropriate topical wound care,
normal routine, such as maintaining a beard or shaving. such as a moist wound dressing.
Ears should be gently inspected for debris or injury. If ● Remove any product with an adhesive
assessed as appropriate, wax softening drops may be backing with utmost care to avoid further
trauma
needed for 3–5 days if cerumen is present and causing ● Secure non-adherent dressing with a gauze
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the patient difficulties with their hearing. Maintaining or tubular non-adhesive wrap
clean nails is another aspect of personal hygiene. Care ● Change dressings according to the
should be taken if nails require trimming, especially if manufacturer’s recommendations
the patient has brittle nails or is diabetic. Documentation ● Record details of skin tear, describe or
photograph wound, record details of
dressings and implementation of measures
to reduce risk of further occurrences
Practice tip

While personal grooming is not vital from a health perspective,
it is a factor in how we see ourselves and how others identify Practice tip
with us. With the many changes that come with illness and Monitor any bruising regularly, as such areas may be at risk of
therapies applied in critical care, it is important to keep the developing skin tears.
patient’s ‘look’ as normal as possible – simple things such as
styling hair or trimming beards – if not for the patients them-
selves, who might be unaware, then for their families.
EYE CARE

The eyes are one of the most sensitive parts of the human
body. If their eyes are not properly cared for, critical care
Skin Tears patients may spend many hours in unnecessary discom-
Dependent patients who require total care are at greatest fort. Simple bedside procedures like turning on lights at
risk of skin tears. Injuries result from routine activities night or assessing pupil reactions can be uncomfortable.
such as dressing, bathing, positioning and transferring. There are a number of physiological processes that protect
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The elderly, those with fragile skin (particularly those the eye. For example, the eye is protected from dryness by
with a history of previous skin tears), those who require frequent lubrication facilitated by blinking. Antimicro-
the use of devices to assist lifting, those who are cogni- bial substances in tears help prevent infection, and the
tively or sensorily impaired, and those who have skin tear ducts provide drainage. When the eye is unable to
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problems such as oedema, purpura or ecchymosis are at close properly, tear film evaporates more quickly. If any
greatest risk. Most skin tears occur on the arms and the of these defence mechanisms are compromised the eyes
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back of the hands. The Payne-Martin classification system are at greater risk.
uses three categories to describe skin tears: skin tears There is considerable risk to patients’ eyes while they are
without tissue loss; skin tears with partial tissue loss; and in the ICU. The blink response may be slowed or absent
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skin tears with complete tissue loss.
in some patients, such as individuals receiving sedatives
Skin tears can be prevented by careful handling of patients and muscle relaxants, or those with Guillain–Barré syn-
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to reduce skin friction and shear during repositioning drome. A number of complications can result, such as
and transfers. Padded bed rails, pillows and blankets can keratopathy, corneal ulceration and viral or bacterial con-
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be used to protect and support arms and legs. Paper-type junctivitis. Corneal abrasions may occur within 48 hours
or non-adherent dressings should be used on frail skin, of ICU admission 11,12 and in up to 40–60% of critically
and should be removed gently and slowly. Wraps or nets ill patients. 8,12 When the eyes are exposed they are at
can be used instead of surgical tape to secure dressings greater risk of injury and infection, and conjunctival
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and drains in place. Application of a moisturising lotion oedema can lead to subconjunctival haemorrhage. For
to dry skin helps to keep it adequately hydrated. Treat- the intensive care patient, who often has multiple intra-
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ment of skin tears is outlined in Table 6.3. The focus of venous lines, nasogastric tubes, ventilation tubes and
nursing care should be on careful cleansing and protec- their various connections, there is potential to uninten-
tion of the skin tear to prevent further damage and docu- tionally damage one of the eyes with one of these devices
mentation of interventions and healing progress. during position changes.