Skin Management and Pressure Ulcer/Injury Prevention
The skin is the largest organ in the body. Because skin becomes thin, fragile and loses elasticity with age, elderly people are at increased risk for skin injuries.
Common skin injuries in older people:
Hydration and nutrition play a vital role in achieving and maintaining skin health. Additionally, skin reflects the overall health of the body, so the presence of skin injury and be indicative of an overall health issue. It is important that we assist the resident in maintain properly moisturized skin, some ways you can do this include but are not limited to:
Encouraging fluid intake and providing fluids of their choice. If they don’t like what you are offering, offer something else. Any fluid is better than nothing.
Reporting to the nurse if you notice a change in the resident’s skin condition, such as increased dryness, change in color, change in texture, change in temperature
Applying lotion or cream in the morning and at bedtime
In all cases, make sure you are referring to the resident’s orders and plan of care to ensure what you are providing falls within guidelines.
While we want skin to be hydrated, what we don’t want is prolonged exposure to moisture, such as that from urine or feces. When skin is exposed to urine or feces, it becomes irritated and is more susceptible to breakdown. Feces, especially, is damaging to skin due to the enzymes present in the feces itself.
Incontinence management can be very important in preventing skin injuries, especially those caused by pressure. Following individualized toileting programs, using the appropriate incontinence product and using appropriate cleansing and moisture-protection products are all ways to help minimize the damage caused by exposure to feces or urine. Many facilities have an incontinence management program that includes the use of moisture-barrier cream for everyone who is incontinent. Check with the charge nurse and resident care plan to see if this is in place that the facility you are working.
A pressure injury is when there is localized damage to skin and/or underlying soft tissue typically over a boney prominence or caused by a medical or other device. It’s very painful, especially in beginning stages of damage.
Prevention is important in preventing the onset of a pressure injury/pressure ulcer. When a resident admits to the nursing home, he/she should be assessed by a nurse to determine his or her risk of developing a pressure injury. Risk factors that place someone at higher risk for skin breakdown include but are not limited to:
Co-morbid conditions, such as diabetes
Urinary and/or fecal incontinence
Malnutrition and/or hydration deficits
Resident refusal of some aspects of care or treatment
Some medications, such as steroids, that may affect healing
Impaired diffuse or localized blood floor
When caring for a resident, if you notice a change in skin color, especially over a bony prominence, report to the nurse immediately. This can be a sign of damage that is starting to occur. People with darkly pigmented skin are high increased risk for developing pressure injuries, since it is more difficult to notice a change in skin color.
An effective intervention for prevention or treatment of a pressure injury, is relieving of constant pressure or repositioning. Refer to the resident’s plan of care to determine how frequently he or she needs to be assisted with repositioning.
Having a good supportive surface in the resident’s wheelchair or on their bed is great and very important but does not take the place of repositioning. When assisting with repositioning, it is important to pay special attention to heels and elbows, as they are more prone to damage due to it being difficult to redistribute pressure in these areas.
Make sure you pay attention to heels and buttocks for residents who are in a wheelchair all the time. These are the two most common areas for pressure injuries to occur.
When positioning someone in bed, pay special attention to make sure their heels are floated off the mattress. If you are using some kind of heel protector, make sure it actually relieves pressure from the heels, as some of the older models don’t and are not effective in preventing pressure injuries.
Other areas to watch for signs of breakdown are the shoulder blades on the back, especially for thin residents who are bed bound, as well as the bridge of the nose (glasses) and behind the ear for those who wear oxygen.
If you have a resident who has contractures or prefers to lay on his or her side, make sure you put some cushion between the knees to prevent pressure in that area.