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Skin and Wound Care:
Prevention, Risk Factors, and Treatment
Skin acts as a barrier that protects residents from infections and environmental threats. When skin remains healthy and moisturized, it can better retain moisture, defend against harmful pathogens, and support overall well-being. On the flip side, damaged or compromised skin increases the risk of infections, pain, and other complications. Understanding how to protect this vital organ is a critical aspect of resident care.
per year
MORE THAN
$11 BILLION
Caring for pressure injuries costs
17,000 LAWSUITS DIRECTLY RELATED
to pressure injuries ANNUALLY
There are
claim after wrongful death
2ND
MOST COMMON
PREVALENCE
11.8%
LONG TERM CARE
12.0%
REHABILITATION CENTERS
25.2%
LONG TERM ACUTE CARE
SEVERE PAIN and
ACTUAL HARM
which can lead to
F686
CITATIONS
Pressure injuries are often associated with
due to the resident's clinical condition
PREVENTATIVE MEASURES
are taken, some pressure injuries
MAY BE UNAVOIDABLE
Even when all
A thorough admission skin assessment identifies pre-existing pressure injuries or risks and establishes a baseline. Without it, the facility MAY BE HELD RESPONSIBLE for later-discovered injuries.
of pressure injuries occur on the
of pressure injuries occur in the
Complete the assessment within 1 to 2 hours of admission, weekly X4 and weekly ongoing reassessments for residents with pressure injuries.
Skin Assessment
Proper pressure injury management relies on early assessment, timely care, and the right support surfaces to promote healing and prevent complications.
of admission
of pressure injuries often occur within
of admission
of pressure injuries often occur within
Less Accurate in
High-Risk Settings:
Limited predictive power in
critical care and end-of-life cases.Reliability Varies: Higher degree of interrater reliability with registered nurses
Overlooks Key Influences: Doesn't address race, age, or certain diagnoses.
Risk of Misclassification: Can underestimate risk without additional judgment.
Incomplete Coverage: Lacks consideration for equipment needs and positioning.
Misses Some
Risk Factors:
Lacks coverage
for existing or healed wounds, weight loss, and history.
Guides Prevention: Helps direct preventive measures in centers.
Standardized Approach: Offers consistency across caregivers.
Early Risk Identification: Supports timely intervention at admission and with condition changes.
Widely Used:
The most
common tool
for assessing pressure ulcer
risk.Covers Key Domains: Evaluates six essential areas, like mobility and nutrition.
Evaluates six key factors that can contribute to skin breakdown, assigning a score to each factor. The total score determines the resident's overall risk level.
6
Friction and Shear
5
Nutrition
4
Mobility
3
Activity
2
Moisture
1
Sensory Perception
The Braden Scale has limitations that necessitate nurse judgment alongside scores. It may overlook critical risk factors in complex cases. Acknowledging its strengths and weaknesses enhances personalized resident care.
SOURCE: National Pressure Injury Advisory Panel, npiap.com
Mucous Membrane
A pressure injury occurring on mucous membranes, such as inside the mouth or nasal passages. These injuries cannot be staged due to differences in tissue structure compared to skin.
Deep Tissue
Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration. It indicates damage to the underlying soft tissue caused by pressure or shear.
Unstagable
The wound bed may be partially covered by slough that obscures the full extent of tissue damage. The presence of slough makes it impossible to determine the depth of the injury until the slough is removed.
Stage 4
Full-thickness skin and tissue loss with exposed muscle, tendon, bone, or supporting structures such as cartilage. Slough or eschar (dead tissue) may be present, and the wound often includes tunneling or undermining.
Stage 3
Full-thickness skin loss with damage to subcutaneous tissue, possibly showing fat but not bone, tendon, or muscle. It may have slough, tunneling, or undermining.
Stage 2
Involves partial-thickness skin loss, appearing as a shallow wound with a red or pink bed or a serum-filled blister. There may be no slough (dead tissue), and the injury does not expose deeper layers such as fat, muscle, or bone.
Stage 1
Intact skin with non-blanchable redness that doesn’t fade under light pressure. It may include changes in temperature, tissue firmness, or sensation such as pain or itching.
on skin and wound care
explore these helpful resources:
Preventing Pressure Injuries: Key Facts & Figures
Discover these and other valuable tools, resources, and educational materials at:
RiskManagement.HealthCapUSA.com
to Skin and Wound Care:
Prevention, Risk Factors, and Treatment
Friction, like sandpaper, damages skin on areas such as elbows, heels, and coccyx, while shear forces twist and compress blood vessels, often caused by elevating the head of the bed too high or sliding in a chair.
Pressure on bony areas disrupts blood flow, cutting off oxygen and nutrients while causing waste buildup.
Moisture alters skin pH, fosters bacteria, and weakens the barrier. Excessive washing strips natural oils, causing dryness and irritation.
Poor communication and high staff turnover hinder care. Teamwork and clear plans improve skin management.
Over time, skin naturally becomes thinner, drier, and less elastic, making it more prone to breakdown.
Diseases like diabetes, cardiovascular disease, and respiratory issues can impair blood flow, reducing the skin’s ability to heal and increasing the risk of pressure injuries.
Conditions like diabetic neuropathy reduce sensation, meaning residents may not feel discomfort or pain from pressure, leading to delayed detection of skin issues.
Poor nutrition weakens the skin and slows down healing processes, making it more susceptible to wounds.
Skin acts as a barrier that protects residents from infections and environmental threats. When skin remains healthy and moisturized, it can better retain moisture, defend against harmful pathogens, and support overall well-being. On the flip side, damaged or compromised skin increases the risk of infections, pain, and other complications. Understanding how to protect this vital organ is a critical aspect of resident care.
A thorough admission skin assessment identifies pre-existing pressure injuries or risks and establishes a baseline. Without it, the facility MAY BE HELD RESPONSIBLE for later-discovered injuries.
per year
MORE THAN
$11 BILLION
Caring for pressure injuries costs
PREVALENCE
11.8%
LONG TERM CARE
12.0%
REHABILITATION CENTERS
25.2%
LONG TERM ACUTE CARE
SEVERE PAIN and
ACTUAL HARM
which can lead to
F686
CITATIONS
Pressure injuries are often associated with
17,000 LAWSUITS DIRECTLY RELATED
to pressure injuries ANNUALLY
There are
claim after wrongful death
2ND
MOST COMMON
due to the resident's clinical condition
PREVENTATIVE MEASURES
are taken, some pressure injuries
MAY BE UNAVOIDABLE
Even when all
of pressure injuries occur on the
of pressure injuries occur in the
Complete the assessment within 1 to 2 hours of admission, weekly X4 and weekly ongoing reassessments for residents with pressure injuries.
of admission
of pressure injuries often occur within
of admission
of pressure injuries often occur within
Proper pressure injury management relies on early assessment, timely care, and the right support surfaces to promote healing and prevent complications.
Skin Assessment
Guides Prevention: Helps direct preventive measures in centers.
Standardized Approach: Offers consistency across caregivers.
Early Risk Identification: Supports timely intervention at admission and with condition changes.
Widely Used:
The most
common tool
for assessing pressure ulcer
risk.Covers Key Domains: Evaluates six essential areas, like mobility and nutrition.
Less Accurate in
High-Risk Settings:
Limited predictive power in
critical care and end-of-life cases.Reliability Varies: Higher degree of interrater reliability with registered nurses
Overlooks Key Influences: Doesn't address race, age, or certain diagnoses.
Risk of Misclassification: Can underestimate risk without additional judgment.
Incomplete Coverage: Lacks consideration for equipment needs and positioning.
Misses Some
Risk Factors:
Lacks coverage
for existing or healed wounds, weight loss, and history.
Evaluates six key factors that can contribute to skin breakdown, assigning a score to each factor. The total score determines the resident's overall risk level.
6
Friction and Shear
5
Nutrition
4
Mobility
3
Activity
2
Moisture
1
Sensory Perception
The Braden Scale has limitations that necessitate nurse judgment alongside scores. It may overlook critical risk factors in complex cases. Acknowledging its strengths and weaknesses enhances personalized resident care.
These injuries result from inadequate blood flow, often found on the lower legs or feet. They are typically painful, dry, and have well-defined borders. Treating underlying circulation issues is crucial for recovery.
Venous injuries are caused by poor blood circulation, usually in the lower legs. They are shallow wounds with irregular borders that may produce a lot of fluid. Compression therapy is a common treatment to improve circulation and promote healing.
This condition, caused by prolonged exposure to moisture, often affects residents with incontinence. Symptoms range from redness to severe skin breakdown. Managing moisture is key to preventing this painful condition.
Residents with diabetes may develop injuries on pressure points like the soles of the feet. These injuries can progress unnoticed because nerve damage (neuropathy) reduces the sensation of pain. Regular foot checks and proper footwear are essential to prevent complications.
Pressure injuries, also known as bedsores, develop when prolonged pressure is placed on bony areas, restricting blood flow to the skin. This is common in residents who have difficulty moving or are bedridden. Regular repositioning and using specialized cushions or mattresses can reduce the risk of these painful injuries.
Mucous Membrane
A pressure injury occurring on mucous membranes, such as inside the mouth or nasal passages. These injuries cannot be staged due to differences in tissue structure compared to skin.
Deep Tissue
Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration. It indicates damage to the underlying soft tissue caused by pressure or shear.
Unstagable
The wound bed may be partially covered by slough that obscures the full extent of tissue damage. The presence of slough makes it impossible to determine the depth of the injury until the slough is removed.
Stage 4
Full-thickness skin and tissue loss with exposed muscle, tendon, bone, or supporting structures such as cartilage. Slough or eschar (dead tissue) may be present, and the wound often includes tunneling or undermining.
Stage 3
Full-thickness skin loss with damage to subcutaneous tissue, possibly showing fat but not bone, tendon, or muscle. It may have slough, tunneling, or undermining.
Stage 2
Involves partial-thickness skin loss, appearing as a shallow wound with a red or pink bed or a serum-filled blister. There may be no slough (dead tissue), and the injury does not expose deeper layers such as fat, muscle, or bone.
Stage 1
Intact skin with non-blanchable redness that doesn’t fade under light pressure. It may include changes in temperature, tissue firmness, or sensation such as pain or itching.
Preventing Pressure Injuries: Key Facts & Figures
on skin and wound care
explore these helpful resources:
RiskManagement.HealthCapUSA.com