Skin – Stroke Nursing Care in Med-Surg

00:01 Now let's look at the skin as a system.

00:04 This is so important. It's actually your largest organ.

00:08 And our goal here is to prevent skin breakdown.

00:13 Why did I stop? Because if a patient develops skin breakdown, that's on us, okay? If a patient develops a bedsore on our watch, we didn't do our jobs.

00:23 So if we're talking about a pressure sore, or a decubitus ulcer, or a bedsore, those are the names we use.

00:28 But if our patients develop them, it's our fault, okay? And stroke patients have an even higher risk of skin breakdown, because of their immobility.

00:39 Oh, I just gave you the answer to the question.

00:42 Why are stroke patients at a higher risk for skin breakdown? Well, we started talking about it, but let's break it down and unpack it a little more.

00:50 Skin breakdown leads to pressure ulcers, and that's because the skin or underlying tissue is damaged because of a loss of blood flow to that area.

00:58 Okay, that's how they happen, but why is there a loss of blood flow to that area? Where you're really at risk for skin breakdown, the areas like, believe it or not, the back of your head because of the pressure that's there if you're laying in bed all the time, at bony prominences, like elbows, or on your back, or your heels.

01:18 So, first concept I want to keep repeating over and over again that nurses are the ones who prevent skin breakdown.

01:27 So you need to make sure that Mr. Johnson is up and mobile as much as possible.

01:31 If I had a patient who couldn't turn themselves, it's my job to turn them, reposition them, prop them with pillows every 2 hours.

01:40 That's the longest I should let a patient go laying in 1 position.

01:44 I also always want to be on watch looking at their skin and assessing their skin.

01:49 A great excuse, I have never had a patient turn me down asking, "Would you mind if I rub some lotion on your back?" That way, I can turn them over, it's non-threatening, and I can assess their skin all the way down.

02:02 So, again, I promise you, I've never had a patient tell me, "No, no, please. Don't rub my back." Usually, they enjoy that because they've been kind of stiff and being in bed.

02:12 But remember, stroke patients are at an increased risk for skin breakdown, because they're not as mobile as a normal patient or even as they were before the stroke.

02:23 The more pressure points you have on your body, that's going to compromise the blood supply to that area, and the tissue's going to be damaged.

02:31 The first sign that you're heading for skin breakdown is a reddened area, so intervene quickly when you notice that.

02:38 So, it's because they're immobile, because they're sitting or lying more than you normally would.

02:43 They might have some extra edema, or they might have just poor circulation before they ever came in.

02:49 But because they are not as mobile as they were before coming into the hospital, they're at an increased risk.

02:56 Now, things that make it even worse.

02:59 If the patient is a smoker, the circulation is obviously compromised.

03:04 If they have poor nutrition, they're probably likely going to have lower serum protein, and that's going to give us more issues.

03:10 If they're overweight or underweight.

03:13 See, if they're overweight, that's going to be extra pressure.

03:16 If they're underweight, they're going to have more bones sticking out in places that an overweight person wouldn't.

03:22 So, neither one is good for preventing skin breakdown.

03:25 Normal weight is going to be the best.

03:27 If they're incontinent, you can have stool or of urine that's going to be very difficult on their peri area.

03:34 And if they're older, because their skin is much more fragile, then.

03:38 So I know if I have a stroke patient who's not mobile, they're sitting and lying more often, and they're a smoker, or they don't have good nutrition, they're not of normal weight, they're incontinent or they're older, this is going to be a real risk, and I've got to watch them extra closely for skin breakdown.

03:55 Many hospitals do what they call skin rounds and they will go through and look at every patient in the hospital on a certain day of the week, and document what their skin looks like.

04:05 But I want to let you know that skin breakdown might not be there at the beginning of your shift, but the patient can sure develop it in one 12-hour shift if you're not on call.

04:16 So, I want you to practice with Mr. Johnson.

04:19 What position would you put him in? How would you protect his paralyzed side? What things would you do for pressure relief? And what things are involved in proper skin hygiene? Okay. Let's break that down. Now, I wanted you to have a couple of, kind of, some ideas in your mind maybe of what you've seen or what you've read about before.

04:45 But now we've got 5 pictures for you to look at how you would position Mr. Johnson.

04:50 Now, we've given you examples. The dark shaded part is the side that's been affected, so it's either weak or it's paralyzed.

04:58 Now look how we have the patients in each one of these pictures.

05:01 Now we have the paralyzed side in the first one when they're lying on their left side.

05:05 Look at the extremity that's laid out.

05:08 Look at the extremity that we have on the pillow.

05:10 So this patient is right-sided paralysis.

05:14 We have their left leg propped up on a pillow nd you put that pillow underneath their knee and their ankle, because I don't want them torqued at all, right? We have their left arm spread out like that, and then we have their right arm resting on their body. You can also put a pillow underneath there.

05:30 Now I want you to pause the video and pay attention.

05:34 Think through, ask yourself these questions.

05:36 Which side is the patient paralyzed on? Which arm is on a pillow? Where's the right leg? Where's the left leg? Which extremities use pillows? So think through each one of these 5 positions to help you kind of get a frame of reference of how we would safely position a patient on their right, on their left, on their back, or sitting up.

06:04 Okay. Welcome back.

06:05 Hey, I'd encourage you, even if you really wanted to go the extra mile, try this on yourself.

06:10 Pretend that 1 side of your body or the other side of your body is paralyzed.

06:14 Use the pillows in your own bed to practice positioning.

06:18 Now, if you've got a brave family member, if they'll let you practice on them, I recommend you doing that, too.