А – putting off the shirt over the head; b – putting on the shirt on the patient’s hands

Skin Care and Bedsore Prevention

Skin care

An important role in attending serious patients is played by skin care. Human skin performs protective function, takes part in heat exchange and metabolism. That is why skin cleanness and absence of injuries are the main conditions for its normal functioning.

Skin stays elastic, soft and supple due to functioning of oil and sweat glands. However abundant accumulation of fat and intensive hidrosis lead to skin soiling. Together with fat and sweat, microorganisms are accumulated on the skin and cause skin itch. Itch leads to scratches and abrasion, which serve as site of entry for microorganisms to penetrate into the skin thickness. If the skin is not looked after, intertrigos may appear on it.

When the skin is not properly taken care of, when the organism is debilitated and the patient stays immovable in bed for a long period, there may appear solutions of continuity, the so-called bedsores, on the skin where there is lack of subcutaneous fat. The areas of the sacral bone, bladebone, ectotrochanter, elbows, and heels usually serve as such places.

Bedsores

A b edsore is necrosis of skin integument, caused by compression of tissues with trophism disorder.

At early age bedsores appear in cases of diseases or spinal cord disorders, at middle age – debilitated patients who stay in bed for a long time and do not have enough strength to change the position of the body or its parts themselves suffer from bedsores.

Bedsores appear: when the patient lies on the back – in the area of calcaneal tuber, sacral and tail bone, bladebone, on the back surface of elbow joints, rarer – above the acanthas of dorsal vertebra and in the area of external occipital protuberance; when the patient lies in the face-down position – on the front surface of anticnemion, especially above the shins, near the kneecaps and also by the costal margins and anterior superior iliac spines, i.e. in the areas where soft tissues are pressed by the bed surface.

Improper skin care, uncomfortable bed and beds which are rarely remade promote bedsores.

When the patient is inadequately attended, in the area of compression there first appears blanching, which is followed by lividity without distinct borders. Tissues start to look hydropic and they are cold to the touch. Further on epidermis flakes off, there appear blisters and skin necrosis. Patients complain of numbness, and then of slight pain. In grave cases not only soft tissues are subject to necrosis but also the periosteal coverage and panniculus of the bone stock. Addition of infection may lead to sepsis and cause death.

The nurse is to wipe the serious patient’s skin daily with disinfectant solutions: camphor spirit, cologne, vodka or diluted 40% ethyl alcohol, 3% table vinegar (1 table-spoon for a glass of water). The end of a towel is wetted with the solution and the skin is wiped with this towel. Then the skin is wiped dry with the dry end of the towel (better a bath towel). It is very useful to rub the skin energetically. It is possible to use gauze plug instead of the towel.

To avoid bedsores it is necessary to:

1. turn the patient into the lateral position, if possible;

2. smooth out the sheets, to see to it that there are no crumbs in the bed;

3. see to it that there are no patches, folds, etc. on the underclothes and bed linen;

4. put a bed air-pillow under the sacral bone so, that the sacral bone is above the hole of the air-pillow. It is necessary to put on a pillow-slip on the air-pillow beforehand or wrap it with a diaper. Water pillows, foamed-rubber cushions, etc. may be used instead of the air-pillow;

5. rub the skin daily with disinfectant solution: vodka, camphor spirit, cologne, vinegar solution (1 table-spoon of table vinegar for a glass of boiled water) or with a towel wetted with warm water. Then the skin is to be wiped dry and rubbed with a dry towel.

If there appear reddening areas, similar to nascent bedsores, the above-mentioned measures are taken more intensively. UV irradiation, ultra-high-frequency treatment is prescribed.

If there appear blisters, they are to be wiped with 1% brilliant green spirit, then a dry dressing is applied. 1% solution of potassium permanganate may be used.

Iruxol (special drug) contributes to enzymatic debridement. This drug is to be applied twice a day with a wet dressing. The sloughing sphacelous tissue must be removed when changing the dressing. Ointment Fibrolan has the same effect. It is possible to use Vishnevsky ointment, synthomycin emulsion, aerosol Laevovinisolum, panthenol ointment, Solcoseryl – in form of injections or ointment.

Special attention should be paid to cleansing the skin near the perineum – to the patients’ intimate washing because accumulation of urine and faeces may lead to solution of continuity. Intimate washing is carried out with warm (30-35°C) dilution of potassium permanganate or some other disinfectant. It is also possible to use different prepared aseptic decoctions and infusions that allow to maintain cleanness in this area, to take preventive measures against pyoinflammatory complications.

Ewer, dressing forceps and sterile cotton-wool wads are used to cleanse the perineum. Women are more in need of intimate washing. During the procedure the woman should lie on her back, legs bent in knees, hips a bit separated. The bedpan is put under the area of buttocks. An ewer with warm disinfectant solution is taken into the left hand, and the liquid is poured on the vulva and the skin is cleansed with a cotton-wool wad, gripped with dressing forceps, in the direction from the vulva to the anus (top-down). After that the skin is wiped in the same direction with a dry cotton-wool wad.

It is much easier to perform intimate washing of a man: while the patient is in the same position, the water from the ewer is poured onto inguinal folds and perineum. The skin is wiped dry in the same direction.

Intertrigo

Intertrigo is an inflammatory affection of skin folds. It appears oftener in warm seasons, especially if the patient is obese, given to sweating, not following the rules of personal hygiene, when walking a lot, etc. Intertrigo may appear as a result of lack of drying the skin after washing, babies may have it as a result of diarrhea, improper care, etc.

Intertrigo always appears in places where surfaces are contiguous: in inguinofemoral folds, between the buttocks, fingers, toes, under the breasts, in the axillary creases, in the stomach and neck folds if the patient is obese.

Intertrigo declares itself as reddening which is symmetrical on both sides of the skin fold. The skin is wet, sometimes there appear superficial rhagades on it. Intertrigo is accompanied by itch, burning pain and often by ache. In case of postulation joining there appear pustules on the edges of the weeping surface.

In cases of frank inflammation the treatment is reduced to restriction of movement; if needed, bed rest, cold pack with 1% solution of Resorcinum, 3% solution of boric acid, lead water, smearing of skin folds with zinc paste or zinc oxide paste, Dermosolon, Synalar, Lorinden are prescribed.

It is also effective to cleanse the area of intertrigo with a dilution of iodine (1-2 drops for a glass of water) or with boiled water of room temperature without soap. After drying the skin with a soft cotton fabric, an air bath is taken for 15-20 minutes, then the intertrigo is powdered with potato starch or talc.

Preventive measures against intertrigo are: following the rules of personal hygiene, drying the skin after washing, in case of need – abundant powdering with mineral powders: talc, fatty powder with boric acid, Lycopodium.

Face, neck and upper part of the body are to be washed daily. If the patient is strictly confined to bed, the nurse washes him with the help of a sponge and a cotton-wool wad. Hands are to be washed in the morning, before eating and when they get dirty during the day.

Feet are to be washed daily with warm water and soap before going to bed. The feet of a confined to bed patient are to be washed 2-3 times a week putting the wash-basin on the bed (fig.10).