1. Skin Care/Pressure Prevention
Lesson 15
Skin Care/Pressure Prevention

2. Lesson Objectives
The student will be able to explain the purpose of the Integumentary System and the importance of preventing skin breakdown.
The student will be able to identify factors which contribute to skin breakdown, the types of residents at greatest risk and the most common sites for skin breakdown.
The student will be able to list the components of a good skin care program ant the role of the Nursing assistant.
The student will be able to list some pressure-reducing devices and explain hoe to apply/utilize them
The student will be able to explain the stages of decubitus ulcers.
The student will be able to identify other types of wounds and associated potential complications.

3. Integumentary System Skin largest organ Three layers
a. Epidermis- top layer of skin
b. Dermis- middle layer that contains sweat glands, oil gland, nerve endings, and blood vessels
c. Subcutaneous (fat layer)- bottom layer of skin. Insulates body and give elasticity to skin

4. Skin Function
Sensation
Temperature control
Excretion
Protection

5. Normal Aging Dry, thin, fragile Loses elasticity Wrinkles/sags
Subcutaneous layer decreases
1. cold feeling
2. brown (age) spots

6. Skin Breakdown (pressure ulcers)
Skin breakdown can occur when individuals stay in one position too long (2 hours or more)
Pressure reduces blood supply causing skin to become damaged
Most pressure ulcers develop within few weeks of admission. Why?
Most likely to develop on bony prominence and friction areas. Can you name some of both?

7. Areas of skin breakdown
Bony Prominences
Ears
Back of head
Shoulder blades
Elbows
Hips
Coccyx
Knees
Heels
Ankles
Friction Areas
Armpits
Under breasts
Skin folds
Groin
Inner thighs
Between buttocks
Between toes
Around contracted area
Under tubing

8. Who is at greater risk for pressure ulcers?
Residents with impaired mobility
Residents who are incontinent
Residents who are obese
Malnutrition
Residents with a history of pressure ulcers

9. Other factors that put residents at risk
Impaired sensory perception-medicines, medical conditions, and altered mental status
Moisture- incontinent of bowel and bladder and heavy perspiration
Poor nutritional and hydration status
Friction and shearing
Chronic illness
Age
Tubing
Depression/Mental illness

10. Braden Scale
Used by the nurse to assess a residents level of risk for developing pressure ulcers
Six criteria: sensory perception, moisture, activity, mobility, nutrition, and friction
Rate from 6-23, lowest score the higher the risk
Nursing assistant needs to know which residents are at higher risk

11. Preventing pressure ulcers
Reposition residents at least every 2 hours
Prevent shearing during lifts/moving. How?
Check incontinent residents often
Avoid heavy soap usage
Use moisturizing lotion to dry skin areas and gently massage bony prominences regularly
Use pillow to prevent skin to skin contact
Keep heels off bed
Promote good nutrition and hydration
Provide smooth and wrinkle free bed
Devices used to help prevent pressure ulcers
Pressure reducing beds/mattresses/chair pads
Heel boots
Bed Cradle (see procedures)
Anti-decubitus pad
Heel/elbow protector

12. Stages of pressure ulcers
Redness that doesn’t go away after pressure is relieved; skin intact

13. Stages of pressure ulcers
Broken, cracked, or blistered area surrounded by redness; superficial wound depth

14. Stages of pressure ulcers
Skin over wound is gone with underlying tissue exposed; may be covered with necrotic tissue or contain purulent exudate

15. Stages of pressure ulcers
Extensive tissue damage; muscle and bone visible

16. Treatment Methods Medications- antibiotics and analgesics (pain meds)
Wound treatment- antibiotic ointments/ creams and dressings
Nutritional supplements- promotes wound healing
Physical therapy- wound debridement
Surgical interventions

17. Circulatory Ulcers
Stasis ulcers
Arterial ulcers
Caused by poor blood return to heart from legs/ feet causing small veins to rupture
Skin is brown, dry leathery , and hard
Common sites: heels, and inner ankles
Very painful and can make walking difficult
Slow healing and get infected easily
Open wounds on legs and feet caused by diminished blood flow through arteries
Cold, blue, shiny skin appearance
Pain usually worse at night
Common sites: top of toes, outer ankle, and heel
Injury and disease that decrease arterial blood flow: hypertension, diabetes, smoking, and age

18. Observations to report to the nurse
Redness that does not go away
Drainage
Pain
Swelling
Burning sensation

19. Test Review (A) Flexibility (B) Cold air (C) Good circulation
1. Which of the following is a condition that increases the risk of pressure ulcers?
(A) Flexibility
(B) Cold air
(C) Good circulation
(D) Restricted mobility
2. Which of the following statements is true about pressure ulcers?
(A) Pressure ulcers are usually caused by exercising too much.
(B) Pressure ulcers are difficult to heal but do not hurt much.
(C) Pressure ulcers are impossible to prevent.
(D) Pressure ulcers can lead to life-threatening infections.
3. Which of the following is at a higher risk of skin breakdown?
(A) Front of neck
(B) Face
(C) Tailbone (sacrum)
(D) Hands
4. A nursing assistant should reposition immobile residents at least every
(A) Two hours
(B) Three hours
(C) Ten minutes
(D) Twenty minutes

20. Test Review (A) Hand roll (B) Bed cradle (C) Trochanter roll
5. A __________ keeps the covers from pushing down on a resident’s feet.
(A) Hand roll
(B) Bed cradle
(C) Trochanter roll
(D) Draw sheet
6. Which of the following statements is true of the skin?
(A) It feels heat, cold, pain, touch, and pressure.
(B) It becomes more elastic as a person ages.
(C) It is the chemical substance that is created by the body and controls body functions.
(D) The epidermis is the inner layer of the skin.
7. One way a nursing assistant can help with normal changes of aging related to the integumentary system is to
(A) Withhold fluids so a resident will not go to the bathroom often
(B) Clip toenails frequently
(C) Keep sheets wrinkle-free
(D) Rub lotion into red or irritated spots on the resident’s skin
8. Which of the following descriptions of a resident’s skin does NOT require reporting
(A) Skin is pink and intact
(B) Skin is pale, cool, and dry
(C) Skin is red, moist and warm
(D) Skin is cracked, dry and pink

21. Test Review
9. When floating the heels of a resident, the nursing assistant should
(A) Place a pillow under the ankles
(B) Place a pillow behind the knees
(C) Place a pillow behind the calves
(D) Place a rolled blanket under the calves
10. Which of the following areas are at risk for friction sores?
(A) Heels, coccyx, ears
(B) Shoulders, elbows, back of head
(C) Spine, knees, tops of toes
(D) Thighs, breasts, arm pits
11. The Braden Scale is used to assess________?
(A) The resident’s level of risk for developing skin breakdown
(B) The resident’s level of mobility
(C) The residents level of aspiration risk
(D) The resident’s level of nutrition
12. How does the skin appear when it first begins to break down?
(A) Skin looks like a deep crater.
(B) Skin turns pale, white, red, or purple.
(C) Skin is covered with bruises.
(D) Skin has raised blisters.

22. Test Review
13. Which of the following descriptions pertains to a Stage 1 ulcer?
(A) Extensive tissue damage; muscle and bone visible
(B) Skin over wound is gone with underlying tissue exposed; may be covered with necrotic tissue or contain
purulent drainage
(C) Broken cracked, or blistered area surrounded by redness; superficial wound depth
(D) Redness that does not go away after pressure is relieved; skin intact
14. Which of the following descriptions pertains to a Stage 4 ulcer?
15. Which position is known to cause increased pressure to the coccyx area?
(A) Lateral
(B) Supine
(C) Semi-Fowler’s
(D) Fowler’s