1. Misty Bailey Edwards, BSN, RN, CWOCN Princeton Baptist Medical Center

2. * Skin: A Brief Overview * Skin Assessment * Risk Factors for Skin Breakdown * Prevention of Skin Breakdown * Moisture Associated Skin Damage * Documentation * Conclusion

3. * Medicare Reimbursement * Legal Aspects * Appropriate and Prompt Treatment of any Skin Issues

4. * Epidermis: Outermost layer * Basement Membrane: Anchors the epidermis to the dermis * Dermis: The thickest layer that forms “true skin”; Contains capillaries, nerve endings, sweat glands, hair follicles, and other structures

5. * Protection: The body’s LARGEST organ * Physical barrier from the outside environment * Protection from physical abrasion, bacterial invasion, dehydration, and UV radiation * Regulation * Sweat glands and capillaries contained in the dermis * Uses sweating and changes in blood flow to regulate temperature when exposed to extreme highs or lows * Sensation * Contains abundant nerve endings and receptors * Detects stimuli related to temperature, touch, pressure, and pain

7. * Should be performed at least upon admission, every shift, and with every change of caregiver (and per facility’s policy otherwise) * Important for the prevention of pressure ulcers and moisture associated skin damage * Should include assessment of: * Skin Temperature * Edema * Change in skin consistency with surrounding tissue * Localized pain

8. * Consider: * Texture * Dryness/Flakiness * Erythema * Lesions * Maceration/Denudation * Color Changes * Blanching/Non Blanching * Patient’s Positioning (Contractures, Mobility, etc) * Any Medical Devices in Use

10. * Use natural light/halogen (Fluorescent gives illusion of bluish tint) * May be unable to assess blanching vs. non blanching * Look for areas that are darker than the surrounding skin * Warmer temperature to an area than the surrounding skin * Indurated, shiny, or taut areas

11. * Increased dryness * Loss of Elasticity * Sun Exposure * Rhytides or “Wrinkles” * Tan/Brown Macules/Patches

13. * Braden Scale * Sensory Perception: Ability to respond meaningfully to pressure-related discomfort * Moisture: Degree to which the skin is exposed to moisture * Activity: Degree of physical activity * Mobility: Ability to change/control body position * Nutrition: Usual food intake pattern * Friction/Shear: Depends on the level of assistance patient requires with moving and the level of muscle strength

14. © Barbara Braden and Nancy Bergstrom, 1998 All rights reserved

15. * Low Risk * 23 to 20 * Medium Risk * 19 to 16 * High Risk * 15 to 11 * Very High Risk * 10 to 6 * * A Braden Score of 18 or below indicates an INCREASED RISK for pressure ulcers

16. * Age * Sun Exposure * Dehydration * Soaps * Nutrition * Medications * Drug/Alcohol/Tobacco Use * Bed Bound Patients * Immobility * Multiple Co-Morbidities (i.e. Diabetes, ESRD) * Infection * Decreased Oxygen/Ventilator Dependent * Incontinence to Urine and/or Stool

18. * Avoid positioning on an area of erythema * Keep the skin clean and dry * Do not massage/vigorously rub an area that is at risk for pressure ulcers * Protect the skin from excessive moisture * Keep the skin moisturized and hydrated appropriately to prevent skin damage

19. * Air Overlays for Mattress * Low Air Loss/Alternating Pressure Mattress * Foam Wedges for Turning/Offloading * Heel Suspension Devices/Boot

20. * Black, et al. listed several recommendations for the use of wound dressings in pressure ulcer prevention put together by a group of experts in the field from Australia, Portugal, the UK, and the USA * These recommendations included considering the use of a five-layer silicone bordered foam dressing to enhance, but not replace, pressure ulcer strategies for the sacrum, buttocks, and heel * * Note there are several types/brands of foam dressings available which are being used for prevention

21. * Routine turning every 2 hours * Support bony prominences * Suspend heels off of the bed * Gatch knees to decrease shearing/friction * Use draw sheet for repositioning * Keep the head of bed at 30 degrees or below if possible

22. * Research with pressure mapping studies have shown that the number of layers of linen directly correlates with pressure ulcer risk * More Layers of Linen = More Risk for Pressure Ulcers * Tips: * Assess for a “Moisture Management Plan” to determine the linen needed * Communicate this with any staff working with you (i.e. Nursing Assistants, Techs, LPNs, etc)

24. * Skin breakdown related to incontinence to stool and/or urine * Prolonged/repetitive exposure to urine/stool * May begin as redness or tenderness * If untreated, skin can become macerated and even progress to skin loss

26. * A consistently applied, defined, or structured skin care regimen (Doughty, et al. JWOCN 2012) * Product Selection * Selected based on consideration of individual ingredients and broad product categories such as cleanser, moisturizer, or skin protectant * Skin Care Regimen Should Include: * Timing, Cleansing, Moisturizing, and Protecting

27. * Timing: Cleansing should occur as soon as possible following an incontinent episode * Cleanse with a pH balanced cleanser (mimic the pH of the skin, 4-5.5) using a soft cloth to decrease friction with the skin * Routine moisturizer to replace lipids in the skin and restore the barrier function of the skin * A variety of moisture-barrier skin protectant products available that vary in ability to protect the skin from irritants, macerations, and maintain skin health

28. * Dimethicone Based * Emollient properties soften and moisturize the skin * Forms a protective, water resistant cover to lock in moisture, and provide a barrier between the skin and urine/stool * Works well for prevention of breakdown in intact skin * Petrolatum Based * Provides a moisture barrier to the skin * Locks out moisture from urine/stool * Works well for prevention of breakdown in intact skin * Zinc Oxide Based * Typically thicker barrier * Works well in prevention for heavily incontinent patients * Works well in treatment of denuded skin *Several brands available; Some products may be a combination of the above ingredients * Some products include an antifungal component to treat IAD

29. * Occurs within skin folds * Most often a result of trapped moisture due to sweating * May appear as a fissure or linear cut in the skin fold * Commonly seen under breasts or within abdominal folds * May often hear a patient state that she has “yeast” in this area; However, ITD can be caused by various types of bacteria and may not be strict

30. * Daily cleansing to these areas * Dry these areas thoroughly following bath * May use cloth to “wick away” moisture from these areas * Powder to help absorb moisture * Daily cleansing to the affected areas * Dry thoroughly * Use cloth to “wick away” moisture; A silver impregnated cloth is available that treats ITD well

31. * Minimize the time between an incontinent episode and the time of cleaning/changing * Use absorptive products appropriately (diapers/under pads) * Diaper checks with turning * Do NOT use additional diapers, under pads, or towels tucked into the patient’s diaper * Appropriate use of skin barriers, along with a skin care regiment in incontinent patients PREVENT MASD

33. * Head to toe skin assessments should be documented upon admission, every shift, and with every change of caregiver * Any skin breakdown should be noted within your documentation and pictures should be taken per your facility’s policy

34. * Be as specific as your facility’s electronic medical record (EMR) or other documentation system allows * It never hurts to add an additional note if the EMR allows it to further document your findings * Be sure to note wound or skin breakdown was present on admission * If you suspect that it is a pressure ulcer, make sure that you know your facility’s policy on staging and follow it * You can never document too much!

35. * Document any changes or deterioration of wounds or skin breakdown during the hospital stay * Make sure that the WOC nurse or wound care staff has been notified if there are any wounds/skin breakdown and document that they have been consulted * If you did not assess (“lay eyes”) on a wound, do NOT document that you did * Communication Helps Consistency * Communicate any wounds/skin breakdown noted during report to the next shift * Communicate what the wound/skin looked like when you assessed it

36. * Routine turning/repositioning should be documented * Any preventative measures in place should be documented (i.e. Mattresses/Overlays, devices, preventative dressings, etc) * Diaper changes/checks should be documented if possible * Document any education provided to the patient and/or family * If you don’t document, it didn’t happen!

37. * Assessment, Prevention, and Documentation together makes up a process that is critical to bedside nursing * If just ONE of the components is missing, nursing care is incomplete or appears to be incomplete * Ensuring that all three steps are followed through will ensure that patients are receiving the highest quality of care possible! Assess Prevent Document

38. * Black, J., Clark, M., Dealey, C., Brindle, C., Alves, P., & Santamaria, N. (2014). Dressings as an adjunct to pressure ulcer prevention: Consensus panel recommendations. International Wound Journal, 12(4), 484-488. * http://www.npuap.org/wp-content/uploads/2015/02/2.- Preventive-Skin-Care-M-Goldberg.pdf http://www.npuap.org/wp-content/uploads/2015/02/2.- Preventive-Skin-Care-M-Goldberg.pdf * Slachta, P. (2013). Assessing risk of pressure- and moisture- related problems in long-term care patients. Wound Care Advisor, 2(3).