This document discusses various factors that can cause skin damage, including pressure, shear, friction, and moisture. It provides examples of how shear and friction can damage skin, such as when pulling a patient up in bed or during a slide transfer. Risk factors for skin breakdown are also outlined, including age, impaired mobility, nutrition status, and medical conditions. Tools for assessing risk like the Braden Scale are presented. Stages of pressure ulcers from I to IV are defined along with images. The importance of regular skin assessment is emphasized.

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

9. Shear and Friction

10. Causes of Skin Damage
Moisture:
.

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.

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

18. Equipment

19. Factors Increasing Risk
Equipment: pneumoboots
Spinal Cord injury: (Braces and stabilizing equipment)
Neurological disorders
Chronic medical conditions:
diabetes, COPD, CHF
History of pressure ulcers
If have stage I, 10X greater risk of developing higher stage
Preterm neonates
Obesity/ Thin: 30 >BMI< 19

20. Factors Increasing Risk
Critical Lab: Prealbumin level
(reflects Visceral Protein Stores)
Mild depletion = 10-15
Moderate depletion = 5-10
Severe depletion = < 5

21. Highest risk factors
 >70 years  stroke
 impaired mobility  pneumonia
 current smoking  CHF
 low BMI  fever
 altered mental state  sepsis
 urinary and fecal  hypotension
incontinence  dry and scaly skin
 malnutrition  history of pressure
 restraints ulcers
 cancer  anemia
 diabetes  lymphopenia
 hypoalbuminemia

22. ALL patients require a
R. A at Admission & every 24 hours.

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

25. RISK ASSESSMENT:
Low score=high risk
*The Braden Scale •The Norton Scale


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 = ---------------

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

38. Presure Ulcer Staging
Stage I
Dark Skin

39. Pressure Ulcer Staging
Stage I

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.

41. Pressure Ulcer Staging
Stage II

42. Presure Ulcer Staging
Stage II

43. Presure Ulcer Staging
Stage II

44. Pressure Ulcer Staging
Stage II

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.

46. Presure Ulcer Staging
Stage III

47. Stage III
Pressure Ulcer Staging

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

49. Pressure Ulcer Staging
Stage IV

50. Pressure Ulcer Staging tage IV
S

51. Stage IV

52. Stage IV

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.

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.

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.

62. Moving and changing
position
• Help persons

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

65. Moving and changing position

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)

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.

71. Pressure Ulcers are “mostly” Preventable
causes

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

79. 79

81. Infection

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)

84. Products
• Hydrophyllic
• Hydrogel
• Alginate
• Foam
• Accuzyme
• panafil

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