11/12/2015
Skin Care, Skin Tears and
Pressure Ulcers
Objectives
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Donna Flahr RN BSN IIWCC
MSc (WHTR)
Penny Fentiman BSc OT
4.
To discuss the function of the skin.
To review prevention of skin damage.
To discuss options in the assessment and
management of skin tears and pressure
ulcers.
To discuss pressure management options
in pressure ulcers.
The Skin
Skin Function
The skin is the largest organ in the body.
It is necessary for temperature control,
sensation and electrolyte balance.
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It is our greatest protector!!
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Protects from bacterial entry
Protects from toxins
Maintains fluid balance
Provides for a sense of touch
Keeps underlying tissues from drying out
Social-interactive
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The Importance of Skin Protection
The Effect of Friction
There are a variety of things to consider when
discussing skin protection:
 Friction
 Moisture
 Nutrition
 Fluid intake
 Sensation
 Possible sources of pressure/trauma
The rubbing of skin causing a
decrease in its protective
ability.
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Sheets
Poor fitting socks / shoes
Casts / prosthetics
The Effect of Shear
Moisture and its Effect on the Skin
Shear is a force produced
when adjacent surfaces
slide across one another
e.g. skin and mattress,
causing stretching, pulling
and kinking of the blood
vessels, resulting in
ischemia.¹
Maceration - allows bacteria to
penetrate the skin.
Skin does not tolerate moisture for lengthy
time periods, wetness destroys its natural
barrier² to bacterial invasion.
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The Importance of Nutrition/Hydration
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Nutrition is very important to skin health.
A balanced diet of vegetables, meat and
fruit is necessary for general health.
Hydration is also important to skin
maintenance: what happens when skin
dries out?
Assessing Tissue Damage/Skin
Tears
Risk factors for skin tears
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Advanced age or immature skin
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Compromised nutrition
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Cognitive impairment
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Multiple medications
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Impaired mobility
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Dry skin/dehydration
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Sensory impairment
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Chronic disease (Renal failure, HF, CVA)
The Importance of Sensation
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Insensate individuals are at an increased
risk of tissue loss; pain is an important
protector from pressure related injury.
Remember sedation reduces the ability to
respond.
Individuals with dementia may not be able
to articulate pain.
Preventing Skin Tears
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Recognize fragile skin
Exercise caution when bathing and
dressing these individuals (most skin
tears occur during ADL’s)
Avoid use of traditional tapes (use
microadherent tape – Mepitac or paper
tapes)
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Skin Tear Management
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If there is a flap of skin remaining post
injury attempt to roll it back over the open
area using a q-tip.
Cleanse any open areas with saline (duel
top) or SeaClens held 4-6 inches from the
wound.
Skin Tear Management Cont’d
A non-adherent dressing over the open area or
flap (e.g. Mepitel or Adaptic), and then a cover
dressing secured with Kerlix, Retallast (Burn
Net) or Surgilast (minimize the use of tape on
skin).
 Try and leave the dressing intact for as long as
possible after the initial dressing application to
get skin adherence.
Key Point: When you change the dressing make
sure to lift it off in the direction the skin is laid
(indicate with an arrow).
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Some Other Dressing Options
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Mepilex foam (without the border) secured
with gauze wrap or burn net.
Mepilex Border
Minimize dressing changes (promote moist
wound healing) and protect the area to
increase the likelihood of closure.
Key Points!
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Recognition of risk and prevention of
injury is key.
Minimize ongoing trauma to tissues by
minimizing dressing changes and tape
removal.
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Pressure Ulcer Prevention
Possible Sites of Pressure Damage
Adapted from: Agency for Health Care Policy and
Research. Treating pressure sores. Consumer guide,
Number 15. AHCPR Publication Number 95-0654.
Rockville (MD): U.S. Department of Health and
Human Resources; 1994. p. 5. Used with permission of
AHCPR.
How to Maintain Skin???
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Inspect skin
frequently for signs
of pressure
Look for any areas of
redness, swelling or
firmness.
Re-position the
resident off the area
and re-check it again
in 30 minutes.
Do Not Rub Reddened
Areas!!!!
Supine Position
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heels, sacrum, elbows,
scapulae, back of head
Lateral Position
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Medial and lateral malleoli,
greater trochanter, ear
Prone Position
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toes, knees,
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cheek and ear
Sitting Position
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elbow, sacrum/coccyx,
ischium
Staging Pressure Ulcers
Stage One: Observable color change of intact
skin. Persistent reddened area
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Stage 2
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Partial thickness skin loss: a blister or
shallow injury.
Stage 3
Full thickness injury with or without
undermining.
Stage 4
Stage X
Full thickness skin damage down to bone,
tendon and supporting structures.
Wound bed is covered with eschar and depth
cannot be assessed.
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Suspected Deep Tissue Injury
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characterized by a purple localized area of
discolored intact skin or a blood-filled blister due
to damage of underlying soft tissue from pressure
and/or shear.
Presentation may be preceded by tissue that is
painful, firm, mushy, boggy, and warmer or
cooler than adjacent tissue.
Things that can influence
pressure
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Proper inflation of a Roho cushion.
Proper placement of a cushion on the
wheelchair.
Use of incontinent products
Identifying to the OT that something has
changed.
What Prevents Pressure Ulcers
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Looking
Completing routine risk assessment
(Braden Scale)
Pressure Management: turning and repositioning schedules, mobilization,
pressure management equipment (heel
boots, specialty surfaces, wheelchair
cushions).
Cushion Options
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Basic foam cushion
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T-foam
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“Sling eliminator”, “rigidizer”
Acton Gel
Sits under the cushion to take the “hammock”
of the vinyl seat and provide a flat, level base.
Combination cushions
J cushion
Inside the cover of the J cushion
Higher level positioning and skin protection
Gel at the back for ischial bones, coccyx
(tailbone)
Bones sink into the gel
•Solid base
• “trough” for leg position, cut out at the back for the
gel which also serves to help keep the bottom to the
back of the chair
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Air cushions
Different types of ROHO
Low Profile Roho
ROHO: Multiple air pockets or cells, set to allow the
bottom to “immerse” or sink into the cushion, and
distribute pressure over the whole bottom rather than at
the bones.
Quadtro High Profile
Enhancer Roho
Positioning the cushion
Has the green and red button on the front. Green button
pushed in – all cells are open. Red pushed in means
locked in place
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Cushion use
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Do not place padding, soaker pads,
blankets on top of the cushion
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These decrease the effectiveness of the
cushion in positioning and pressure
management
Once the Pressure is Managed
Let’s Assess the Wound
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Measure (length, width, depth)
Exudate (amount, quality)
Appearance (describe the wound bed appearance,
tissue type and amount)
Suffering (client pain level using validated pain
scale)
Undermining (presence or absence)
Re-evaluate (monitor all parameters on a regular
basis)
Edge (condition of wound edge and surrounding
skin)
Bed Surfaces
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Static: overlays (T foam, gel), sheepskins,
Roho sections
Dynamic: low air loss and alternating
pressure mattresses.
Fowler positioning option
How to Measure??
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Measure the length times the width
(longest x widest).
The longest part of the wound is the length
no matter which direction it is.
The width is the longest axis perpendicular
(at 180°) to the length.
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Let’s measure this one!
What about depth?
Describe the Exudate
Type: serous, serosanguinous, purulent or just
describe the color.
Amount:
• Small – dressing is ‹ 25% saturated, wound bed is
moist
• Moderate – dressing is 50-75% saturated, wound
bed is moist
• Large – dressing is › 75% saturated, wound bed
is wet
Maceration
Wet, white, waxy soft looking tissue,
indicative of too much moisture in the wound.
Think dressings!!
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Describe the wound tissue
Some examples of wound tissue
Appearance: wound tissue (granulation tissue,
slough, etc.)
Edges (attached, unattached, etc.)
Periwound skin (red, macerated, etc.)
What are you looking for? What should your
description help with?
Slough – loose yellow or grey green tissue
Eschar
Suffering
Black or grey may be wet or dry and hard;
often firmly attached.
So do you think any of the wounds I have
shown you are painful?
Do you assess for pain?
Don’t assume that because they don’t
complain there is no pain!
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An Example of a Pain
Assessment Tool
Undermining
The Importance of measuring
regularly
Tracking Progress
What is it?
How is it measured?
How do you describe it?
Why is it important?
How do you know when things are improving,
or not?
How often do you measure?
What do you document on?
Why is this important?
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What About Managing the
Pressure Ulcer?
Proper cleaning technique:
“Use enough irrigation pressure to
enhance wound cleansing without causing
trauma to the wound bed” Sk Pressure Ulcer
What Solution Should I Use?
Use an Isotonic solution (usually saline)
“ Fluid used for cleansing should be warmed
to at least room temperature” Sk Pressure Ulcer
Guidelines, 2004
Guidelines, 2004
What About Periwound Protection?
What About Packing?
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When do you use packing?
How much?
What kind?
How often
How do you decide when to stop?
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What About Deep Wounds?
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Do you irrigate wound that you can’t see
the bottom of?
How do you decide what’s safe?
When and who do you ask for further
direction?
Recognizing Infection
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Non-healing
New breakdown
Exudate, erythema, edema
Smell
Red friable tissue + bleeding
What About the Cover Dressing?
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No matter what dressing product you use it
must be in contact with 2” of good skin in
order to support absorption.
You must look after the individual with the
wound first! If you do not manage the other
co-morbidities you will not attain healing.
To Culture Or Not to Culture?
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Make sure you give the lab all of the pertinent
information: location, change in drainage, local
symptoms.
Cleanse the wound by spraying the wound with
normal saline or sterile water prior to taking the
swab. Don’t culture eschar or exudate.
Center the swab in the wound base and rotate it
firmly (use sufficient pressure to cause bleeding);
make sure to keep away from wound edges.
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11/12/2015
Things That can Influence Healing
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nutrition
medications
local blood supply
infection
co-morbidities
patient adherence
local wound care
stress
The Importance of Early Referrals
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Immobility is one of the leading causes of
pressure related skin injury. Physiotherapists are
integral in increasing mobility!
Occupational therapists can assist with the
selection of the type of bed surface to use, the
type of seating or heel pressure relief devices.
Dietitians referral is crucial to prevention and
management of acute and chronic wounds
Psychosocial Factors
Wounds are socially isolating
Skin integrity changes impact on QOL!
Include the resident and family: education is
the key to compliance and potential
success!
Interdisciplinary Team
This is the Gold Standard of prevention and
something that we, as health care
professionals, should be working toward.
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You Can Do It!!!
References
Prevention of wounds poses a considerable
challenge for healthcare providers in all
care settings.⁴
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2.
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4.
Weir D Pressure Ulcers: Assessment, Classification and Management of Pressure Ulcers. In:
Krasner DL et al, Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 4th
ed. 2007. Wayne PA. Health Management Publications, Inc.
Newman DK, Preston AM, Salazar S, Moisture Control, Urinary and Fecal Incontinence and
Perineal Skin management In: Krasner DL et al, Chronic Wound Care: A Clinical Source Book for
Healthcare Professionals, 4th ed. , 2007 . Wayne PA. Health Management Publications, Inc.
Skin Tear management Guidelines; Molnlycke Health Care: The Art and Sciance of Wound Care:
The Fundamentals of Wound Management
Colburn L. Prevention of Chronic Wounds In: Krasner et. al. Chronic Wound Care: A Clinical
Source Book for Healthcare Professionals (3rd ed), Wayne PA, 2001.
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