BASIC SKIN CARE AND PREVENTION OF

PRESSURE ULCERS
OVERVIEW
The outside covering of the body, or the skin, serves three major purposes. It
prevents dehydration, regulates body temperature, and is the major deterrent of
infection in the body. When this barrier is broken, whether by surgical incision,
wound, cut, or scrape, the primary defense is no longer intact. Superficial breaks in
the skin may be treated on an outpatient basis.
BASIC SKIN CARE
Good skin care and healthy lifestyle choices can help delay the natural aging
process and prevent various skin problems.
Some skin problems are markedly aggravated by soap and water, and
bathing routines are modified according to the condition. Denuded skin, whether the
area of desquamation is large or small, is excessively prone to damage by
chemicals and trauma.
The friction of a towel, if applied with vigor, is sufficient to produce a brisk
inflammatory response that causes any existing lesion to flare up and extend.
1. PROTECT YOURSELF FROM THE SUN
Lifetime of sun exposure can cause wrinkles, age spots and other skin
problems as well as increase the risk of skin cancer.

Use sunscreen. Broad-spectrum sunscreen with an SPF of at least

15. Apply generously and re-apply every 2 hours (more often if
swimming or perspiring)
Seek Shade. Avoid the sun between 10 am 2 pm, when the suns
rays are strongest.
Wear protective clothing.

2. DONT SMOKE
Smoking narrows the tiny blood vessels in the outermost layers of skin, which
decreases blood flow. This depletes the skin of oxygen and nutrients that are
important to skin health.
3. TREAT YOUR SKIN GENTLY
Limit bath time
Avoid Strong Soaps
Shave Carefully
Pat Dry
Moisturize dry skin
4. EAT A HEALTHY DIET

5. MANAGE STRESS

PRESSURE ULCERS
A pressure ulcer starts on the skin and often progresses to deeper tissue; it is
caused by impaired circulation to the tissue from pressure over a period of time.
Without adequate blood flow and the nutrition it brings, the tissue will die. Those
often affected are confined to a wheelchair or bed, and unable to move themselves,
not reducing the pressure frequently enough. The usual sites of pressure ulcers, or
bedsores, are on bony prominences, such as the buttocks, sacrum, heels, knees,
and hips.
ETIOLOGY
Pressure ulcers are due to localized ischemia, a deficiency in the blood supply
to the tissue. The tissue is compressed between two surfaces, usually the surface of
the bed and the bony skeleton. When blood cannot reach the tissue, the cells are
deprived of oxygen and nutrients, the waste products of metabolism accumulate in
the cells, and the tissue consequently dies. Prolonged, unrelieved pressure also
damages the small blood vessels.
RISK FACTORS
Several factors contribute to the formation of pressure ulcers:
FRICTION AND SHEARING
IMMOBILITY
INADEQUATE NUTRITION
FECAL AND URINARY INCONTINENCE
DECREASED MENTAL STATUS
DIMINISHED SENSATION
EXCESSIVE BODY HEAT
ADVANCED AGE
CHRONIC MEDICAL CONDITION Diabetes and Cardiovascular
Disease

PATHOPHYSIOLOGY

RISK FACTORS
FRICTION
AND
SHEARING
IMMOBILITY
INADEQUATE
NUTRITION
FECAL AND URINARY
INCONTINENCE
DECREASED
MENTAL
STATUS
DIMINISHED SENSATION
EXCESSIVE BODY HEAT
ADVANCED AGE
CHRONIC MEDICAL
CONDITION Diabetes
and Cardiovascular
Disease Blood Supply
Inadequate
in the tissue

The cell is deprived with

Oxygen and Nutrients

Tissue Dies

Pressure Ulcers

SIGN AND SYMPTOMS

FOUR STAGES OF PRESSURE ULCERS:

STAGE I: non-blanchable erythema signaling potential ulceration.

STAGE II: partial-thickness skin loss (abrasion, blister, or shallow crater) involving
the epidermis and possibly the dermis.

STAGE III: full-thickness skin loss involving damage or necrosis of subcutaneous

tissue that may extend down to, but not through, underlying fascia. The ulcer
presents clinically as a deep crater with or without undermining of adjacent tissue.
STAGE IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone,
or supporting structures, such as a tendon or joint capsule. Undermining and sinus
tracts may also be present.

RISK ASSESSMENT TOOLS

BRADEN SCALE
The Braden Scale for Predicting Pressure Sore Risk consists of six subscales:
sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A
total of 23 points is possible and an adult who scores below 18 points is considered
at risk. For best results, nurses should be trained in proper use of the scale.
NORTONS PRESSURE AREA RISK ASSESSMENT FORM SCALE
Includes the categories of general physical condition, mental state, activity,
mobility, and incontinence. A category of medications is added by some users,
resulting in a possible score of 24. Scores of 15 or 16 should be viewed as
indicators, not predictors, of risk. The Braden and Norton tools should be used when
the client first enters the health care agency and whenever the clients condition
changes. In some long-term care facilities, a risk assessment scale such as the
Braden or
Norton scale is done on admission and then on a regular basis, usually
weekly. This increases awareness of specific risk factors and serves as assessment
data from which to plan goals and interventions to either maintain or improve skin
integrity.

REFERENCE
Mayo Clinic Staff. Skin Care: 5 Tips for Healthy Skin. (December
16, 2014) Retrieved From: http://www.mayoclinic.org/healthylifestyle/adult-health/in-depth/skin-care/art-20048237?pg=2
Mary DuGiulio, RN, MSN, APRN, BC, Donna Jackson, RN, MSN,
APRN, BC, Jim Keogh. Medical-Surgical Nursing DeMystified A
Self-Teaching Guide. (2007).
Suzanne C. Smeltzer, Brend Bare. Brunner & Suddarths
Textbook of Medical-Surgical Nursing 10th Edition. (2010)

PRINCIPLES OF ASSESSING COMMON PRESSURE SITE

Ensure the lighting is good, preferably natural or fluorescent, because

incandescent lights can create a transilluminating effect.
Regulate the environment before beginning the assessment so that the room
is neither too hot nor too cold. Heat can cause the skin to flush; cold can
cause the skin to blanch or become cyanotic.
Inspect pressure areas for discoloration. This can be caused by impaired
blood circulation to the area. The pressure areas should have brisk capillary
refill when gently pressed with a finger or thumb.
Inspect pressure areas for abrasions and excoriations. Abrasions can occur
when skin rubs against a sheet. Excoriations can occur when the skin has

prolonged contact with body secretions or excretions or with dampness in

skin folds.
Palpate the surface temperature of the skin over the pressure areas (warm
your hands first). Normally, the temperature is the same as that of the
surrounding skin. Increased temperature is abnormal and may be due to
inflammation.
Palpate over bony prominences and dependent body areas for the presence
of edema, which feels spongy or boggy.

INTERPRETING TEST RESULTS

Culture to check for bacteria content.

CBC to evaluate the hemoglobin and hematocrit for oxygen-carrying
capabilities.
Albumin and pre-albumin levels to check on nutrition.
Chemistry to evaluate fluid status.

TREATMENT
Treatment is based on relieving pressure and providing adequate nutrition.
Wound treatment is aimed at preventing infection and encouraging healing. Stage I
and stage II wounds may heal with conservative treatments. However, stage III and
stage IV wounds often require surgical debridement and skin grafting. Treatment
choice depends on the stage of the wound.

Clean wound with soap and water or saline.

Debridement to clean away dead, devitalized, and infected tissue.
Debridement methods include surgery, topical enzymatics, and mechanical
debridement.
Dressings to protect the wound and keep it moist, which promotes healing.

Hydrocolloids which keep moisture in.

Nonadherant dressings, such as aquaphor.
Bulk dressings to absorb copious drainage.
Semipermeable dressings which allow for transfer of gases but are
impermeable to liquids.
Antibiotic ointment for infected wounds.
Oral antibiotics.
Specialized matresses.
Whirlpool treatments.

NURSING DIAGNOSES

Impaired skin integrity

Impaired physical mobility
Nutrition altered: less than what body requires

NURSING INTERVENTION

Prevention is the key to pressure ulcers.

Mobility or repositioning of patients unable to move themselves; every 1 to 2
hours.
Proper nutrition to encourage healing.
Adequate fluid intake.
Remove pressure from stage I areas.
Use pillows to reduce pressure.
Use specialized wheelchair cushions to reduce pressure.
Daily skin inspection.
Stop smoking in order to increase oxygen to tissues.
Daily measurement of wounds to assess status including length, width, and
depth.

REFERENCES
Audrery Berman,Ph.D, RN, Shirlee Snyder, EdD, RN. Kozier & Erbs Fundamentals of
Nursing Concepts, Process and Process Ninth Edition. (2012)
Mary DiGiulio, RN, MSN, APRN, BC, Donna Jackson, RN, MSN. APRN, BC, Jim Keog.
Medical-Surgical Nursiong Demystified A Self-Teaching Guide. (2007)