8. Causes of Skin Damage:
Pressure, Shear, Friction, Moisture
Examples of Friction:
Heels and elbows which aid in movement for
bedridden patients.
Agitated patients or those experiencing seizures.
Superficial abrasion or blistering
11. Shear
Shear is the interaction of gravity and friction causing
twisting or kinking of blood vessels.
Shear occurs when the skeleton moves, but the skin
remains fixed to an external surface.
12. Examples of Shear:
Pulling patient up in bed
Patient in Fowler’s position who slides
down in bed
Slide patient from bed to stretcher.
13. Friction
Friction contributes to pressure ulcer formation
by damaging the skin at the epidermal-
dermal interface, the basement membrane.
Friction ulcers are generally superficial and
easily reversed, unless the cause is not
removed.
14.
15.
16.
17. Factors Increasing Risk
Advanced Age : decreased elastic fibers.
More than 50% of pts with pressure sores >70
Decreased sensory perception
Peripheral Vascular Disease
Impaired Circulation
Edema
Vasoconstriction drugs
MI/ Stroke, Trauma/fractures
GI bleed
23. Skin Safety: Risk Assessment
Reassessment:
Every 24 hours
(Pressure ulcers can develop within 24 hours
of insult or take as long as 5 days to
present.)
Change in condition
(surgery, nutrition, level of mobility, etc)
24. Braden Scale
The Braden score is the total of the
subcategory scores.
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
26. Sensory Moisture Activity Mobility Nutrition Friction &
perception shear
No impairment Rarely moist Walks No Excellent 4 No apparent
4 4 frequently 4 limitation 4 problem 3
Slightly Occasionally Walks Slightly Adequate 3 Potential
limited 3 moist 3 Occasionally 3 limited 3 problem 2
Very limited Moist 2 Chairfast 2 Very Properly Problem
2 limited 2 inadequate2
Completely constantly Bedfast 1 Immobile 1 Very poor 1
limited 1 moist 1
Total Total Total Total Total Total
Grand total = ---------------
27.
28. Risk for Pressure Ulcers
Norton scale
• A score of 14 or less indicate risk for pressure ulcers; score
under 12 indicates high risk
Physical Mental condition Activity Mobility Continence
condition
Good 4 Alert 4 Walks frequently full 4 Good 4
4
Fair 3 Apathetic 3 Walks with help 3 Slightly Occasional
limited 3 incontinence 3
Poor 2 Confused 2 Sit in chair 2 Very limited Frequent
2 incontinence 2
Very poor 1 Stuporous 1 Remain Bed 1 Immobile 1 Urine & fecal
incontinence 1
Total Total Total Total Total
Grand total = ---------------
29. Sensory Perception
Defined as:
The ability to respond meaningfully to pressure
related discomfort.
Score on scale of 1-4
1. Completely limited
Unresponsive or inability to feel pain
2. Very limited
Sensory impairment, moaning or restlessness
3. Slightly limited
Some sensory impairment, can’t communicate need to
be turned.
4. No limitations
Has no sensory deficits
30. Moisture
Defined as:
the degree to which skin is exposed to
moisture.
Score on scale of 1-4:
1. Constantly Moist
Sweating, incontinent, noticed each time pt is turned
or moved.
2. Moist
Often moist, linen changed 1x/ shift
3. Occasionally moist
Extra linen change 1x/day
4. Rarely moist
Skin is usually dry, linen changed routinely
31. Friction & Shear
Score on scale of 1-3
1. Problem
Requires max assist for moving
Sliding against sheets is impossible
Frequently slides down in bed
Agitation leads to almost constant friction
2. Potential Problem
Requires minimal assist for moving
Skin slides to some extent on sheets
Occasionally slides down in bed or chair
3. No apparent problem
Moves independently
Lifts up completely during move
Maintains good position in bed or chair
32. Activity
Defined as:
the degree of physical activity.
Score on scale of 1-4:
1. Bed fast
Confined to the bed
2. Chair fast
Ability to walk is almost non-existent, must be assisted
into chair.
3. Walks occasionally
Short distances, infrequent, most of time in bed or
chair.
4. Walks frequently
Walks outside of room 2x/day
Walks inside of room q 2 hours.
33. Nutrition
Defined as “usual food intake pattern.”
Score on scale of 1-4
1. Very poor
Never eats complete meal
Takes fluid poorly
NPO/ IV fluids only >5 days
2. Probably inadequate
Rarely eats a complete meal
Occasionally will take supplement
3. Adequate
Eats ½ of most meals
Will take supplement if miss meals
On TPN or adequate tube feedings
4. Excellent
Eats every meal
Does not require supplements
40. Presure Ulcer Staging
Stage II
• Stage 2: Partial thickness skin loss involving
epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an
abrasion, blister, or shallow crater.
45. PrPresure Ulcer Stagingessure Ulcer
Staging skin loss
Full thickness Stage III
involving damage to, 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.
48. Pressure Ulcer Staging
Stage IV
Full thickness skin loss
with extensive
destruction, tissue
necrosis, or damage to
muscle, bone, or
supporting structures
(e.g., tendon, joint,
capsule). Undermining
and sinus tracts also may
be associated with Stage
IV pressure ulcers
53. Unstageable/Unclassified:
The top layer of the sore is covered by
dead tissue, which may have a yellow, tan,
gray, green, or brown color. It may also
look like a scab. The dead tissue or scab
covers a deeper, more serious wound and
needs to be removed to be evaluated.
54.
55.
56.
57.
58. Assessment:
Assesses total skin condition at least twice a
day
Dry skin, Moist skin, Breaks in skin
Erythema
Blanching response
Warmth
Oozing & Odor
Evaluates level of Mobility
Restrictive devices
Peripheral Pulses, Edema.
59.
60. Minimize pressure for All patients
Consider pressure relieving devices:
Special bed: Matrix mattresses and Bari-beds
Z-flow positioning pillows
Increase mobility and activity status whenever
possible.
Minimally, turn patients every 2 hours
Encourage weight shifting every
15 min in chair.
Reposition every 1 hour if patient is
unable to do it themselves.
61. Mobility
*Use lifts and hovermats with
positioning.
Turn q 1-2 hours
Post turning schedule
Encourage ambulating
outside of the room
at least BID.
63. • Skin Care
• Skin inspection daily at end of the shift, Look closely at
bony areas for redness or temperature changes.
• Wash skin with warm (not hot) water and use a mild
soap. This will reduce irritation and dryness.
• Apply lotion to keep the skin from Drying Out.
• Gently Massaging intact skin may help with
circulation and comfort. Avoid massaging bony
areas.
• Keep clothes and bed sheets dry. Protect the skin
from sweat and urine.
64. • Minimizing Friction and Shearing is also
important through Proper Repositioning,
Transferring, and Turning techniques.
Bed Sheets & Blankets are Dry and
Wrinkle-Free (smooth).
• Malnutrition should be treated
• Active and Passive range-of-motion
66. Moisture
Implement toileting schedule.
Cleanse skin gently
Do not use hot water
Apply skin barrier after each cleansing
Protect skin with duoderm
Contain urine, stool, wound drainage, etc.
Keep skin folds dry.
67. Friction & Shear
Use transfer devices
Use minimum of 2 people + draw sheet
to pull pt up in bed.
Don’t drag the patient
Keep HOB at or < 30 degrees
Use trapeze
Pad skin surfaces (duoderm)
(elbows/heels)
68.
69. Do not raise the head of the bed too high. .
Cause skin damage to the lower back and
buttocks areas.
Use a bed sheet or other device to help
move the person.
Do not allow the person to lie or sit on a
pressure ulcer. Move and change the
person’s position regularly.
70. Reassessment:
Re-inspect and palpate ALL patients
every 8- 24 hours.
Re-inspect when transferring between
units.
Re-inspect after long procedures, ie:
dialysis, MRI’s, etc.
73. Pressure Ulcer Treatment
Admit Treatment
assessment Plan
Quality
Improvement/
Monitor Program
Weekly
Re-assess
74. Surgical intervention
Débridement
Incision and drainage
Bone resection
Skin grafting.
75. Measure wounds upon admission and
weekly (or with significant changes).
Note the location, size, depth, color of
wound bed and surrounding tissue and
describe the drainage.
76. Size:
Measure length, width and depth of
wound.
Measuring tools are available in unit
storerooms.
Describe wound as a clock with
patient’s head at 12:00 and their feet at
6:00 to promote consistency in
descriptions.
77. Types of debridement
• Autolytic – (Occlusive Dressings) the body
heals itself
• Mechanical – using gauzes
• Enzymatic – chemical enzymes
(Collagenase, Papain, )
• Sharps – scalpel, laser, surgery
• Biosurgical – maggots, leeches
82. Signs of Infection
• Delayed Healing
• Change in Exudate
• Change in Pain
• Change in Granulation Tissue
• Change in Smell
• Change in Size
• Fever
• Leukocytosis
83. Topical Dressings
• Occlusive Dressings
• Divided into polymer films, polymer foams,
hydrogels, hydrocolloids, alginates, and
biomembranes.
• Dressings left in place until fluid leaks from
the sides (3 days to 3 weeks)
85. Transparent Film
• Autolytic debridement
• Partial thickness wounds
• *Stage I or II pressure ulcers
• Superficial burns
86. Hydrocolloids (Autolytic)
• Primary or secondary dressing
• *Partial and full thickness wounds
• Pressure ulcers
• *Necrotic wounds
• Granular wounds preventative dressing
• Used as a secondary dressing or under
compression
87. Hydrogels
• Stage 2 to stage 4 pressure ulcers
• Partial and full thickness
• *Painful wounds
• Skin tears
• Minor burns
• *Necrotic wounds
88. Collagens
• *Infected Wounds
• Tunneling Wounds
• Surgical Wounds
• Can be used with other topical agents
• *Not for necrotic wounds
89. Negative Pressure Therapy
• VAC Device
• For Nonhealing wounds and fecal
incontinence
• Removes Interstitial Fluid from the
wound
90. Antimicrobial Dressings
• Infected Wounds
• Controls bacteria bioburden
• Effective against a broadspectrum of
microorganisms
• IODOSORB
• AQUACEL
• IODOFLEX
91. Saline –soaked Gauze
Dressings
• Saline soaked and not allowed to dry
• Similar to occlusive dressings
• However, Time intensive for nursing
• *Used for Partial and full thickness wounds
• Draining wounds
• Wounds requiring debridement packing,
Or management of tunnels, tracts or dead space
• Surgical incisions/Burns/pressure ulcers
92. FOAM
• Nonocclusive absorptive wound dressing
• Partial and full thickness
wounds…minimal to heavy drainage
• Stage II to IV press. Ulcers
• *Infected and non-infected
93. Skin Safety Team
Team Members:
Physicians
Administrative sponsor
Clinical Educators
Nutrition
Director of PT/OT
Nursing Managers
Nursing Head Nurses
Performance Improvement
Respiratory Therapy
Many staff nurses
Ad hoc: Product manager
Ad hoc: Electronic Medical Records staff member