1. Maintaining skin integrity, it can be done!
“Nurse, I See RED…..”
Maintaining skin integrity, it
can be done!
Developed by: Carol Balcavage, RN, WOCN, 2004

2. “The Nursing Assistant”
The Audience
This education program was designed for the caregiver who spends the most time at the patient’s bedside . . .
“The Nursing Assistant”

3. Objectives The learner will identify the cause of pressure ulcers.
The learner will identify factors that contribute to the development of a pressure ulcer.
The learner will identify the role of the Nursing Assistant in prevention of pressure ulcers.

4. The Patient’s Skin Largest organ in the body, equals
12-15% of body weight and receives one third of the body’s circulating blood volume
Functions
Protection
Thermoregulation
Sensation
Metabolism

5. Maintaining Skin Integrity
Is everyone’s responsibility
Patient’s first line of defense from infection
Many forms of skin integrity issues
Bruises, skin tears, cracks, shearing, erosions, scratches, blisters, pressure ulcers
Hospital acquired pressure ulcers are of great concern

6. What is a Pressure Ulcer?
Any injury caused by unrelieved pressure that damages the skin and underlying tissue (fat, muscle, bone). Also called decubitus ulcers, pressure sores or bed sores
Severity ranges from reddening of skin to deep craters extending to muscle and bone

7. Why are Pressure Ulcers a Problem?
Pressure ulcers can produce poor outcomes for patients including loss of a limb or even death
Pressure ulcers are costly
Increased length of stay
Added hospital costs
Additional recovery time
Pain
Potential for litigation

8. Risk Factors Moist skin Limited activity and mobility
Perspiration
Incontinence
Wound drainage
Limited activity and mobility
Inability to change position independently in bed or in chair
Assistance required to get out of bed
Assistance required to walk

9. Risk Factors Loss of sensory perception
Paralysis (loss of voluntary motion and/or sensation)
Neuropathy (“pins & needles” sensation in affected limb, decrease in sensation)
Decrease in mental awareness

10. Risk Factors Altered blood flow Decreased flow of blood to extremities
Vascular patients
Diabetic patients
Edema
Hypotensive episode (low BP)

11. Risk Factors Friction and Shearing
Friction – abrasion of the top layer of skin
Shearing – the skin separating from underlying tissues

12. Risk Factors
Poor nutrition
Poor hydration

13. What Does a Pressure Ulcer Look Like?

14. What Does a Pressure Ulcer Look Like?
There are four stages of pressure ulcer plus unstageable
Stage I: the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues

15. Special Consideration for Pigmented Skin
Check skin compared to an adjacent or opposite area on the body
Skin temperature (warmth or coolness)
Tissue consistency (firm or boggy feel)
Sensation (pain or itching)

16. What Does a Pressure Ulcer Look Like?
Stage II: ulcer is superficial and
presents clinically as an abrasion,
blister or shallow crater
Stage III: full thickness of skin is
lost, exposing the subcutaneous
tissue
Stage IV: full thickness of skin and
subcutaneous tissue is lost,
exposing muscle or bone

17. What Does a Pressure Ulcer Look Like?
Unstageable: ulcer is covered with
dead tissue which may be black,
brown or yellow

18. What Can You Do to Prevent Pressure Ulcers?
Each person plays an important role
Communication and timely reporting is critical
Other resources are also available such as the patient’s family and friends, the chaplain, volunteers and the WOC/ET nurse
However, it is the “Nursing Assistant” who spends the most time with the patient and who can make the biggest difference in preventing pressure ulcers

19. Prevention: Decrease Excessive Moisture
Good skin care
Bathe patient daily paying particular attention to skin folds and perineal tissues
Use skin cleansers with a low pH and skin protectant on all incontinent patients and patients who use a bedpan
Place absorbent material between the skin folds of obese patients

20. Prevention: Decrease Moisture
Good Skin Care
Limit use of diapers to patients who are out of bed or who have large amounts of urine or diarrhea at one time
Check incontinent patients frequently
Discuss a toileting schedule with the RN
Avoid plastic barriers and sheepskin
Communicate any signs of redness to RN

21. Prevention Sensory Perception
Inspect patient’s skin for areas of redness with every position change
Avoid massaging or rubbing bony prominences (Use a gentle touch when cleansing skin and applying ointments)
Turn and reposition every two hours (minimum)
Elevate heels off of bed surface
Check position of foot in the heel protection device and reposition as necessary

22. Prevention Sensory Perception
Remove compression stockings for ½ hour twice each day and check heels. If patient is at risk for heel breakdown, check more frequently
Perform active and passive range of motion (ROM) of all involved extremities

23. Prevention: Activity/Mobility
Encourage patient to change position frequently or turn and reposition patient every two hours
If patient is not moving because of poor pain control, discuss with the RN
Promote ambulation at regular intervals (consider PT consult if patient has difficulty with mobility)

24. Prevention: Activity/Mobility
Out of bed to chair no longer than two hours at one sitting
Reposition in chair after one hour. If patient is able to do so, remind to shift position every 15 minutes
Hint: Suggest that position be shifted each time there is a commercial on TV
Use chair cushion if patient is at risk

25. Prevention: Altered Circulation
Report the following unexpected changes to the RN:
Change in vital signs and color
Change in temperature of skin surfaces
Decrease in urine output
Swelling in any body tissues

26. Prevention: Altered Circulation
Keep in mind that patients with altered circulation are susceptible to skin damage from heat and cold from items such as:
Heating pads
Hot packs
Cold packs

27. Prevention: Friction/Shearing
Use moisturizers on dry skin surfaces where applicable and use a bathing system that incorporates emollients like Vitamin E and Aloe
Assess need for assistive devices (heel protectors, extra pillows)
Use turning and transfer aids (i.e., lift sheets, trapeze)

28. Prevention: Friction/Shearing
Prevent shearing by maintaining bed
at 30 degrees or less and gatch knees
when possible
Have patient use a trapeze when indicated
When using lift sheet to move patient to top of bed
Avoid dragging any part of patient’s body
Put socks on patient’s feet
Ask patient to bend knees and to push
against bed surface

29. Prevention: Friction/Shearing
Powder bedpan edges before placing patient on bedpan
Pad patient’s buttocks and or transfer board when getting patient in and out of bed with transfer board
Use elbow protectors when indicated
Maintain proper positioning in chair

30. Prevention: Nutrition & Hydration
Monitor weight on admission and weekly
Monitor fluid status, I & O as appropriate
Monitor/encourage nutritional intake recommendations (target: meal completion over 75%)
Accurately record calorie counts
Give patient nutritional supplements as ordered

31. Prevention: Nutrition & Hydration
Provide patient with hand wipes before and after meals. Also provide opportunity to brush teeth
Whenever possible, get patient out of bed for meals

32. PREVENTION is key!

33. Now let’s test your knowledge
Review
Now let’s test your knowledge

34. Select the best answer A pressure ulcer is a surgical wound.
A patient with poor circulation is not at risk for developing a pressure ulcer.
Pressure ulcers are caused by unrelieved pressure.
No one develops a pressure ulcer at my hospital.

35. Select the best answer
A patient with reduced sensation in his feet is at risk for developing a heel ulcer.
Good nutrition leads to bedsores.
Moist skin due to perspiration is not a risk factor.
A patient who is paralyzed is not at risk for developing a pressure sore.

36. Select the best answer
I really don’t worry about pressure ulcers, that’s the nurse’s job.
All patient’s have red heels.
I report any reddened area to the RN.
I check my incontinent patients every four hours.

37. Select the best answer
I do not need to report every red mark that my patient gets on his skin to the RN.
The RN is the only one who can prevent pressure ulcers.
A little pressure sore on my patient’s foot is not very important.
It takes team work to prevent pressure ulcers and I’m a key player on that team.

38. Answer Key C. Pressure ulcers are caused by unrelieved pressure.
A. A patient with reduced sensation in his feet is at risk for developing a heel ulcer.
C. I report any reddened area to the RN.
D. It takes team work to prevent pressure ulcers and I’m a key player on that team.

39. References
Ayello EA, Baranski S, Lyder CH, Cuddingan J. Pressure ulcers. In:Baranski S and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins: p
Calianno C, Assessing and preventing Pressure Ulcers. Adv Skin Wound Care; 2000; 13(5):
Hess CT. Skin Care Basics..Adv Skin Wound Care 2000; 13(3):
Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults:Prediction and Prevention. Cliical PracticeGuideline,No.3 AHCPR Publication No Rockville,MD:Agency for Health Care Policy and Research; May 1992.
Ratcliff CR,WOCN’s Evidence-Based Pressure Ulcer Guideline. Adv Skin Wound Care 2005; 18(4):
Zulkowski,KM, Tellez R, van Rijswijk L. Documentation with MDS Section M: Skin Condition. Adv Skin Wound Care 2001; 14(2):81-89.

40. Lehigh Valley Hospital Allentown, PA
Developed by:
Carol Balcavage, RN, WOCN, 2005