1. Skin Care Please read through the
slides first, which should take approximately 30 to 45 minutes, followed by completing the online assessment. (You may need to click ‘Slide Show’ on the top line to view the presentation.)
Welcome to your
Skin Care
e-learning
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2. Contents The Skin Daily Routine Care SSKIN Prompt
Reporting and Recording
Risk Assessment
Pressure Ulcers
Prevention of Pressure Ulcers
Treatment of Pressure Ulcers
Moisture Lesions
Pressure Relieving Devices
Complications
Assessment
Skin Care
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3. Skin Care
The skin is the largest organ of the human body; covering and protecting everything inside. It provides a barrier to prevent infection entering the body. It protects our bodies by helping to keep at just the right temperature. The nerve endings close to the surface of the skin allow us to have the sense of touch.
37˚C

4. Skin Care
There are three layers to the skin:
Epidermis; the outermost layer of the skin. It forms the waterproof, protective wrap over the bodies surface. Dermis; the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. Subcutaneous Tissue; is made of fat and connective tissue.
Epidermis
Dermis
Subcutaneous Tissue
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5. Skin Care
Blood vessels supply the skin with nutrients and oxygen. If there is constant pressure on the skin it squeezes the blood vessels and disrupts the flow of blood. If the skin is starved for too long, the tissue dies, and a pressure ulcer develops.
Pressure ulcers, also known as pressure sores, occur when the skin and underlying tissue is damaged.
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Source: NHS Choices

6. Daily Routine Care
The clients history of pressure ulcers will be obtained
from the clients care plan, and transfer records from
other providers.
You need to perform skin examination as a part of the clients
daily routine care.
A history of pressure ulcers is a primary risk factor for the development of new pressure ulcers. People with a history of pressure ulcers are more than five times as likely to develop another pressure ulcer as are patients with no such history.
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Early recognition of pressure ulcers, and of any risk factors associated with the development of a pressure ulcer, is critical to their successful prevention and management.

7. Daily Routine Care L K – for red marks and other evidence of pressure.
When performing skin examination as a part of the clients daily routine, you need to:
L K – for red marks and other evidence of pressure.
TOUCH – with the backs of fingers, not finger tips to feel for temperature changes - warm, hot, hard skin.
ASK
if they are in pain? How does it feel to them?

8. Surface – is the equipment adequate and functioning correctly?
Daily Routine Care
The SSKIN care prompt is a powerful acronym as it
defines and ties best practices together.
Remember:
Surface – is the equipment adequate and functioning correctly?
Skin Inspection – all areas inspected, any redness?
Keep moving – repositioning, recorded, how often?
Incontinence – is the skin clean and dry?
Nutrition – is the clients diet adequate? Supplements? Fluids?

9. Reporting and Recording
If you notice any skin changes you must report to your Line Manager, Community Liaison Nurse and The District Nurse.
You must record the changes in the Daily Report
and Health & Safety book. Complete a Clinical Quality Alert (CQA) and an Incident Report
(SOVA).
You should include in your report the:
Colour
If the skin has broken
When you noticed it
The size - a good way to measure is to
compare the skin change with a size of a coin
Daily Report
Health & Safety Book
CQA
SOVA
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10. This Assessment will be in the Clients Care Plan Folder.
Risk Assessment
A Pressure Ulcer Risk assessment is:
Intended for use by all health care professionals
and completed by the Community Liaison Nurse.
It should not be used in isolation and does not take priority over professional judgement.
Must be documented using the correct tool and reassessed frequently as appropriate or indicated by change of external factors.
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ICCM use the Waterlow score for the assessment risk for pressure area care. With the Waterlow score; the higher the score the higher the risk of pressure ulcers.
This Assessment will be in the Clients Care Plan Folder.

11. Pressure Ulcers Pressure ulcers are caused by sustained pressure
being placed on a particular part of the body.
Interface Pressure – most pressure ulcers are the result of sustained pressure in the immobile person, e.g. pressing the skin down on to a firm surface.
Friction – occurs when the skin is briskly moved over the surface with which it is in contact, e.g. clothing or a mattress.
Shearing Forces – occurs when a person slides down or is pulled up out of a bed or wheelchair.
There are 3 main types of pressure:

12. Pressure Ulcers Where on the body do Pressure Ulcers occur?
What to look and feel for:
Redness / erythema for blanching when finger pressure applied
Pain, soreness
Warmer or cooler area over boney prominence
Boggy feeling
Hardened area
Discolouration - dark red, purple, black
Broken skin / ulcer
N.B. Document any changes and continue to monitor closely

13. Pressure Ulcers Poor Handling Low Resistance to infection Immobility
Conditions; such as Diabetes, MS, Alzheimer's Disease
Underweight
Overweight
Immobility
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14. Pressure Ulcers Incontinence or Moisture Lesions
Poor diet, dehydration or lack of nutrition
Medication
Moist / Sweating
Over 70
Decreased consciousness
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15. Pressure Ulcers Severity of pressure ulcers
Healthcare professionals use several grading systems to describe the severity of pressure ulcers. The most common is the European Pressure Ulcer Advisory Panel (EPUAP) grading system. The higher the grade, the more severe the injury to the skin and underlying tissue.
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16. Pressure Ulcers
Grade One; is the most superficial type of ulcer. The affected area of skin appears discoloured and can appear red against lighter skin tones, or purple/ blue in people with darker-coloured skin. Grade One pressure ulcers do not blanch when pressure is placed on them. The skin remains intact, but it may hurt or itch. It may also feel either warm and spongy, or hard. Grade Two; some of the outer surface of the skin (the epidermis) or the deeper layer of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an open wound or a blister.
Grade one
Grade two

17. Pressure Ulcers Grade Three; skin loss occurs
throughout the entire thickness
of the skin. The underlying tissue is
also damaged, although the underlying
muscle and bone are not. The ulcer
appears as a deep, cavity-like wound.
Grade three
Grade Four; is the most severe type of pressure ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis).
The underlying muscles or bone may also be damaged. People with Grade Four pressure ulcers have a high risk of developing a life-threatening infection.
Grade four
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18. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Read and follow the care plan
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19. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Reposition regularly as stated in the care plan
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20. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Encourage and provide nutrition and fluids
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21. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that;
Sheets and clothes
are crease free
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22. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Encourage mobility
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23. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Use the pressure area equipment that has been identified in the care plan
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24. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Observe and report the condition
and changes of the skin
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25. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that;
Skin is kept clean and dry
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26. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that;
Clients are checked regularly if incontinent with urine or faeces
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27. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that;
Seams from clothes are straight
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28. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that;
The correct moving and handling equipment is used
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29. Prevention of Pressure Ulcers
To provide good skin care and help towards preventing pressure ulcers, you need to make sure that you;
Use the moving & handling technique that is specified in the care plan
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30. Treatment of Pressure Ulcers
Treatment of Pressure Ulcers Treatment for pressure ulcers can vary, depending on the grade of the ulcer. Treatment options may include regularly changing the clients position; using special mattresses and dressings to relieve pressure or protect the skin. In some cases, surgery may be needed.
The clients district nurse will visit the clients home to advise and apply any dressings.
Remember; you should not try any method of treatment without the agreement of all the key people, or before you have received the appropriate training.

31. Moisture Lesions
Moisture Lesions also known as incontinence-associated dermatitis (IAD), is a term used with reference to skin damage caused by excessive moisture. They are characterised by irritation and inflammation. Due to the location of moisture lesions there is often confusion between them and pressure ulcers. Skin damage as a result of excessive moisture is defined as being associated with incontinence and not pressure or shear. However, moisture can contribute to the formation of pressure ulcers.
Moisture Lesion
Pressure Ulcer
Confused

32. Moisture Lesions
Our skin is naturally designed to fight infection and environmental stresses. Its ability to do so is affected
by its pH level.
The level of normal skin should be slightly acidic, at about 5.5pH.
Normal pH of urine is 6.5 – 7pH in the morning and becoming more alkaline by the evening pH
Normal faecal pH is pH
Therefore, if urine and faeces are in contact with the skin
an immediate change in pH will occur; consequently causing an adverse reaction.
The pH level of the skin refers to how acidic or alkaline it is. On a scale of 1-14; with 1 being
the most acidic to 14 being the most alkaline.

33. Moisture Lesions
Moisture lesions can occur in areas affected by urine and faeces, including:
Buttocks
Natal cleft
Perineal area
Between the thighs
Scrotum
Labia
Skin folds
Sacrum (due to severe incontinence NOT pressure)

34. Moisture Lesions
If the skin is exposed to urine and faeces and requires frequent cleansing, the permeability of the skin increases and the natural barrier function of the skin is reduced.
Acc
urate identification is critical to ensure the
correct treatment and prevention is achieved.
A moisture lesion will not heal if treated solely by pressure reduction.
However, the presence of moisture may increase the risk of pressure ulceration, so some pressure ulcer risk management is required.

35. Moisture Lesions In some cases a combined lesion can occur.
This happens when there are elements of one or more
wounds of both pressure and moisture damage; therefore
increasing the risk of a combined lesion.
Assessment and management of incontinence issues is the main way to prevent moisture lesions occurring.
It is important to be aware of all the causes of skin damage and assess the client’s risk, to ensure appropriate management of care.

36. Moisture Lesions
Pressure Ulcers versus Moisture Lesions; Wounds on the sacrum and the buttocks are often classified as pressure ulcers when they may be moisture related.
They can be caused by wound exudate, sweat and unresolved or managed incontinence.
The adjacent table helps to differentiate between pressure and moisture damage.
Resource from 3M learning /

37. Moisture Lesions Moisture lesions often cause pain and distress.
A number of strategies can be adopted to prevent and
treat dermatitis associated with urinary or faecal incontinence.
Four key points to remember:
Incontinence associated dermatitis is a painful condition characterised by irritation and inflammation.
While incontinence can occur at any time, prevalence increases with age.
Routine skin inspection, a cleansing routine and skin protection are essential for prevention.
The goal is to control bladder/bowel function or, if this is not possible, to use an appropriate skin care to reduce risk of skin breakdown.

38. Moisture Lesions PREVENTION IS BETTER THAN CURE
To prevent pressure damage, the
most important factor is to reduce
or relieve pressure.
To prevent moisture damage, the
most important factor is keeping
the skin clean, dry and well hydrated.
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39. Pressure Relieving Devices
Pressure-relieving devices; need to be a 24-hour approach and should include attention of all surfaces used by the patient. The equipment redistributes pressure by spreading the weight over a larger surface area, e.g. mattresses and cushions.
Support surface and any positioning needs should be assessed and reviewed regularly and determined by the results of skin inspection, patient comfort, ability and general state.
Repositioning should occur even when
individuals are on pressure-relieving devices.

40. Pressure Relieving Devices
Mattresses and Cushions; there are a range of special mattresses and cushions that can be used to relieve the pressure. People who are thought to be at risk of developing pressure ulcers, or who have pre-existing grade one or two pressure ulcers, usually benefit from a specially designed foam mattress, which relieves the pressure on their body. Those with a grade three or four pressure ulcer will require a more sophisticated mattress or bed system e.g. a mattress that can be connected to a constant flow of air, which is automatically regulated to reduce pressure as and when required.

41. Pressure Relieving Devices
All equipment that is used within pressure care must: Be cleaned Be correctly used Have evidence of records Be stored correctly Any faults should be recorded Be safe to use Be serviced
DO NOT USE:
Water filled gloves
Artificial sheep skin
Ring cushions
Anything that has not been recommended by healthcare professional

42. Bone and Joint Infection Necrotising Fasciitis
Complications
Blood Poisoning
Gas Gangrene
Cellulitis
Bone and Joint Infection
Necrotising Fasciitis
COMPLICATIONS
Even with the best possible care, complications can
happen from pressure
ulcers and can become life threatening
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43. Bone and Joint Infection Necrotising Fasciitis
Complications
Blood Poisoning Blood Poisoning (Septicaemia) occurs if a person who has a pressure ulcer that is infected has a weak immune system. The infection spreads into their blood and other organs.
Blood Poisoning
Gas Gangrene
Cellulitis
Bone and Joint Infection
Necrotising Fasciitis
COMPLICATIONS
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44. Bone and Joint Infection Necrotising Fasciitis
Complications
Gas gangrene
Gas gangrene is a serious but rare form of infection that occurs when a pressure ulcer becomes infected with the clostridium bacteria.
Blood Poisoning
Gas Gangrene
Cellulitis
Bone and Joint Infection
Necrotising Fasciitis
COMPLICATIONS
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45. Bone and Joint Infection Necrotising Fasciitis
Complications
Cellulitis Infection can spread from the site of the pressure ulcer to a deeper layer of skin. This type of infection is called Cellulitis. It causes symptoms of pain and redness, plus swelling of the skin. It will need to be treated with a course of antibiotics.
Blood Poisoning
Gas Gangrene
Cellulitis
Bone and Joint Infection
Necrotising Fasciitis
COMPLICATIONS
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46. Bone and Joint Infection Necrotising Fasciitis
Complications
Bone and Joint Infection Infection can also spread from a pressure ulcer into underlying joints (Septic Arthritis) and bones (Osteomyelitis.)
Blood Poisoning
Gas Gangrene
Cellulitis
Bone and Joint Infection
Necrotising Fasciitis
COMPLICATIONS
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47. Bone and Joint Infection Necrotising Fasciitis
Complications
Necrotising Fasciitis
Necrotising fasciitis ("flesh-eating" bacteria), is a serious skin infection that causes the tissue to die. It can occur when a pressure ulcer becomes infected with a particular type of bacteria, such as
Group A streptococci.
Blood Poisoning
Gas Gangrene
Cellulitis
Bone and Joint Infection
Necrotising Fasciitis
COMPLICATIONS
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48. Further Information
Preventing pressure ulcers is of national importance. You can access further information from: and Your Community Liaison Nurse
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49. Further Information BEST SHOT! Remember; take your
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50. Congratulations!
You have just completed your Skin Care e-learning. There will now follow a short assessment and course evaluation for you to complete. To continue; please click ‘Return to Course View’.
Final
Assessment
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