Immobility is a significant factor for the development of pressure ulcers within 24-72 hours. Pressure ulcers can occur at least in 2 days in bed rest patients. Some medical diagnoses that cause prolonged bed rest are intra-cranial bleeding, aneurysms, cranial infarction (stroke), cerebral contusion, brain abscess, hydrocephalus, paraplegi, quadriplegi, colostomy, multiple fracture and liver encephalopathy.
Prolonged pressure is a major cause of decubitus ulcers because pressure can cause soft tissue ischemia. Apparently, many other factors also play a role in the occurrence of pressure ulcers such as shear, friction, excessive moisture, and possibly infection (Maklebust & Sieggreen, 2001).
Pressure ulcers occur due to damage or death of the skin to the tissue under the skin, in fact, there are also those that penetrate the muscles and regarding the bones due to continuous suppression of an area so that there is interference with the local blood circulation. Parts of the body that are susceptible to exposure are stressed parts such as the back, sacrum, ischhium and heels (Marison, 2004).
Skin care to prevent pressure ulcers is the role of nurses in an effort to find the best evidence based in patient care.
Preventing these problems is very important because it not only protects patients from dangerous things, but can also reduce patient care costs. Financially, pressure ulcers care increases maintenance costs. The amount of costs that must be incurred due to pressure ulcers and the complications that are caused make all parties who contribute to patient care constantly develop research related to prevention and handling of pressure ulcers.
Prevention of the occurrence of compressive ulcers, among others, first by identifying patients who are at risk of press ulcers using the scale of Norton, Braden or Gosnell and subsequently selected prophylactic intervention (Joseph, 2013).
Related to the role of nurses in the effort to prevent pressure ulcers, Potter and Perry (2005) stated that there were 3 (three) areas of primary nursing intervention in prevention of pressure ulcers, namely (first) skin care which included hygiene care and topical administration, (second) mechanical prevention and surface support which includes the use of beds, provision of positions and therapeutic mattresses and (third) education.
According to Maklebust and Sieggreen (2001), the way to prevent pressure ulcers is pressure management (including shear and friction), by changing position at least 2 hours, supporting surfaces, managing the nutritional status of patients and skin care.
According to Registered Nurse's Association of Ontorio (RNAO) (2005), interventions that can be done to maintain the integrity of the skin are by providing moisturizing moisturizers such as lotions, creams and low alcohol ointments. Damage to the integrity of the skin usually occurs in patients with long bed rest, then over time will cause a press ulcer. To be able to maintain the integrity of the skin of the patient remains good, can be given nursing action over beds and also giving olive oil (Yolanda, 2012).
Sullivan, N. and Schoelles, M. (2013) state that a strategy that can be done to prevent pressure ulcers is to use surface protectors, position patients regularly, optimize nutritional status and moisturize the outer skin. In addition, attention must be paid to the organizational components and components of care coordination. Components of the organization include choosing leaders in team membership, establishing policies and procedures, evaluating the quality process, providing education to staff and written communication regarding treatment plans. While the coordination component is like conducting regular meetings to facilitate communication, legality and learning.
Impaired Skin Integrity - Nursing Diagnosis, Outcomes and Interventions
