scimili.blogg.se - Impaired skin integrity

Impaired skin integrity how to#
Impaired skin integrity free#

Observe for signs associated with swallowing problems (e.g.,Ĭoughing, choking, spitting of food, drooling, difficulty handling oral Have an intact gag reflex (Baker, 1993 Lugger, 1994).Ĥ. Have a greatly increased chance of developing aspiration pneumonia Cardiovascular accident (CVA)Ĭlients with prolonged pharyngeal transit times (prolonged swallowing) The reflex is triggered to the esophageal entry (pharyngeal transit Normally the time taken for the bolus to move from the point at which Not rely on presence of gag reflex to determine when to feed. Of posterior pharyngeal wall (lingual surface) with a tongue blade. Ask client to cough test for a gag reflex on both sides Assess ability to swallow by positioning examiner's thumb and indexįinger on client's laryngeal protuberance. There are multiple causes of swallowing impairment, some of which are treatable (Schechter, 1998).ģ. If new onset of swallowing impairment, ensure that client receives a diagnostic workup. Swallow adequately (Poertner, Coleman, 1998).Ģ. Cognitive deficits can result in aspiration even if able to Oral feeding and use enteral feeding for nourishment (McHale et al,ġ998). If one of these factors is missing, it may be advisable to withhold To follow instructions, hold head erect, and able to move tongue in NIC Interventions (Nursing Interventions Classification)ġ.

Impaired skin integrity free#

Remains free from aspiration (e.g., lungs clear, temperature within normal range).

Demonstrates effective swallowing without choking or coughing.

Swallowing Status: Esophageal Phase, Oral Phase, Pharyngeal Phase.

NOC Outcomes (Nursing Outcomes Classification)

oral cavity or oropharynx abnormalities.

nasal or nasopharyngeal cavity defects.

internal or external traumas tracheal, laryngeal, esophageal defects.

mechanical obstruction (e.g., edema, tracheotomy tube, or tumor).

Perceptual impairment, or facial paralysis)

neuromuscular impairment (e.g., decreased or absent gag reflex,ĭecreased strength or excursion of muscles involved in mastication,.

abnormality in esophageal phase by swallow study.

hyperextension of head, arching during or after meals.

observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing, or choking).

regurgitation of gastric contents or set burps.

unexplained irritability surrounding mealtime.

abnormality in pharyngeal phase by swallowing study.

abnormality in oral phase of swallow study.

coughing, choking, or gagging before a swallow.

weak suck resulting in inefficient nippling.

Nursing Times 115: 12, 26-29.Īuthor: Jacqui Fletcher is chair, Pressure Ulcer Education Core Curriculum Group, and senior clinical adviser, NHS Improvement/England.Abnormal functioning of the swallowing mechanism associated withĭeficits in oral, pharyngeal, or esophageal structure or function

Impaired skin integrity how to#

This article, the third in an eight-part series on the new education framework, highlights what practitioners need to know about risk factors associated with impaired skin integrity, how to check for non-blanchable erythema, and evidence-based interventions to promote skin integrity and prevent pressure ulcers.Ĭitation: Fletcher J (2019) Pressure ulcer education 3: skin assessment and care. A skin module forms part of a new core curriculum for pressure ulcer education to enable nurses and other practitioners to understand the key concepts of effective skin assessment and care. Regularly inspecting patientsâ skin for abnormalities is a key step in pressure ulcer prevention. This article, the third in an eight-part series on the development of a core education curriculum for pressure ulcer prevention and management, discusses effective skin assessment