Lesson 15Skin Care/Pressure Prevention

Lesson Objectives• The student will be able to explain the purpose of the Integumentary

System and the importance of preventing skin breakdown.• The student will be able to identify factors which contribute to skin

breakdown, the types of residents at greatest risk and the most common sites for skin breakdown.• The student will be able to list the components of a good skin care program

ant the role of the Nursing assistant.• The student will be able to list some pressure-reducing devices and explain

hoe to apply/utilize them• The student will be able to explain the stages of decubitus ulcers.• The student will be able to identify other types of wounds and associated

potential complications.

Integumentary SystemSkin• largest organ

• Three layers

a. Epidermis- top layer of skin

b. Dermis- middle layer that contains sweat glands, oil gland, nerve endings, and blood vessels

c. Subcutaneous (fat layer)- bottom layer of skin. Insulates body and give elasticity to skin

Skin Function

1.Sensation2.Temperature

control3.Excretion4.Protection

Normal Aging

• Dry, thin, fragile• Loses elasticity• Wrinkles/sags• Subcutaneous layer

decreases 1. cold feeling 2. brown (age) spots

Skin Breakdown (pressure ulcers)

• Skin breakdown can occur when individuals stay in one position too long (2 hours or more)• Pressure reduces blood supply causing skin to become damaged• Most pressure ulcers develop within few weeks of admission. Why?• Most likely to develop on bony prominence and friction areas. Can

you name some of both?

Areas of skin breakdownBony Prominences

• Ears• Back of head• Shoulder blades• Elbows• Hips• Coccyx• Knees• Heels• Ankles

Friction Areas• Armpits• Under breasts• Skin folds• Groin• Inner thighs• Between buttocks• Between toes• Around contracted area• Under tubing

Who is at greater risk for pressure ulcers?

• Residents with impaired mobility• Residents who are incontinent• Residents who are obese• Malnutrition • Residents with a history of pressure ulcers

Other factors that put residents at risk

• Impaired sensory perception-medicines, medical conditions, and altered mental status• Moisture- incontinent of bowel and bladder and heavy perspiration• Poor nutritional and hydration status• Friction and shearing• Chronic illness• Age• Tubing• Depression/Mental illness

Braden Scale

• Used by the nurse to assess a residents level of risk for developing pressure ulcers• Six criteria: sensory perception, moisture, activity, mobility, nutrition,

and friction• Rate from 6-23, lowest score the higher the risk• Nursing assistant needs to know which residents are at higher risk

Preventing pressure ulcers• Reposition residents at least every 2 hours• Prevent shearing during lifts/moving.

How?• Check incontinent residents often• Avoid heavy soap usage • Use moisturizing lotion to dry skin areas

and gently massage bony prominences regularly

• Use pillow to prevent skin to skin contact• Keep heels off bed• Promote good nutrition and hydration• Provide smooth and wrinkle free bed

Devices used to help prevent pressure ulcers

• Pressure reducing beds/mattresses/chair pads

• Heel boots• Bed Cradle (see procedures)• Anti-decubitus pad• Heel/elbow protector

Stages of pressure ulcers

• Stage 1 • Redness that doesn’t go away after pressure is relieved; skin intact

Stages of pressure ulcers

• Stage 2 • Broken, cracked, or blistered area surrounded by redness; superficial wound depth

Stages of pressure ulcers

• Stage 3 • Skin over wound is gone with underlying tissue exposed; may be covered with necrotic tissue or contain purulent exudate

• Stage 4

• Extensive tissue damage; muscle and bone visible

Stages of pressure ulcers

Treatment Methods

• Medications- antibiotics and analgesics (pain meds)• Wound treatment- antibiotic ointments/ creams and dressings• Nutritional supplements- promotes wound healing• Physical therapy- wound debridement• Surgical interventions

Circulatory Ulcers

Stasis ulcers• Caused by poor blood return to

heart from legs/ feet causing small veins to rupture• Skin is brown, dry leathery , and

hard• Common sites: heels, and inner

ankles• Very painful and can make walking

difficult• Slow healing and get infected easily

Arterial ulcers• Open wounds on legs and feet

caused by diminished blood flow through arteries• Cold, blue, shiny skin appearance• Pain usually worse at night• Common sites: top of toes, outer

ankle, and heel• Injury and disease that decrease

arterial blood flow: hypertension, diabetes, smoking, and age

Observations to report to the nurse

• Redness that does not go away• Drainage• Pain• Swelling• Burning sensation

Test Review

1. Which of the following is a condition that increases the risk of pressure ulcers? (A)Flexibility (B) Cold air(C) Good circulation(D)Restricted mobility

2. Which of the following statements is true about pressure ulcers? (A)Pressure ulcers are usually caused by exercising too much.(B) Pressure ulcers are difficult to heal but do not hurt much. (C) Pressure ulcers are impossible to prevent. (D)Pressure ulcers can lead to life-threatening infections.

3. Which of the following is at a higher risk of skin breakdown?(A)Front of neck(B) Face(C) Tailbone (sacrum)(D)Hands

4. A nursing assistant should reposition immobile residents at least every (A)Two hours (B) Three hours (C) Ten minutes (D)Twenty minutes

Test Review5. A __________ keeps the covers from pushing down on a resident’s feet. (A)Hand roll (B) Bed cradle (C) Trochanter roll (D)Draw sheet

6. Which of the following statements is true of the skin? (A) It feels heat, cold, pain, touch, and pressure. (B) It becomes more elastic as a person ages. (C) It is the chemical substance that is created by the body and controls body functions. (D)The epidermis is the inner layer of the skin.

7. One way a nursing assistant can help with normal changes of aging related to the integumentary system is to (A)Withhold fluids so a resident will not go to the bathroom often (B) Clip toenails frequently (C) Keep sheets wrinkle-free (D)Rub lotion into red or irritated spots on the resident’s skin

8. Which of the following descriptions of a resident’s skin does NOT require reporting (A) Skin is pink and intact (B) Skin is pale, cool, and dry (C) Skin is red, moist and warm (D) Skin is cracked, dry and pink

Test Review9. When floating the heels of a resident, the nursing assistant should (A) Place a pillow under the ankles (B) Place a pillow behind the knees (C) Place a pillow behind the calves (D) Place a rolled blanket under the calves

10. Which of the following areas are at risk for friction sores? (A) Heels, coccyx, ears (B) Shoulders, elbows, back of head (C) Spine, knees, tops of toes (D) Thighs, breasts, arm pits

11. The Braden Scale is used to assess________? (A) The resident’s level of risk for developing skin breakdown (B) The resident’s level of mobility (C) The residents level of aspiration risk (D) The resident’s level of nutrition

12. How does the skin appear when it first begins to break down?(A)Skin looks like a deep crater.(B) Skin turns pale, white, red, or purple.(C) Skin is covered with bruises.(D)Skin has raised blisters.

Test Review13. Which of the following descriptions pertains to a Stage 1 ulcer? (A) Extensive tissue damage; muscle and bone visible (B) Skin over wound is gone with underlying tissue exposed; may be covered with necrotic tissue or contain

purulent drainage (C) Broken cracked, or blistered area surrounded by redness; superficial wound depth (D) Redness that does not go away after pressure is relieved; skin intact

14. Which of the following descriptions pertains to a Stage 4 ulcer? (A) Extensive tissue damage; muscle and bone visible (B) Skin over wound is gone with underlying tissue exposed; may be covered with necrotic tissue or contain

purulent drainage (C) Broken cracked, or blistered area surrounded by redness; superficial wound depth (D) Redness that does not go away after pressure is relieved; skin intact

15. Which position is known to cause increased pressure to the coccyx area? (A) Lateral (B) Supine (C) Semi-Fowler’s (D) Fowler’s