Hygiene, Mobility, and Skin Integrity

Hygiene, Mobility, and Skin Integrity

Maintaining skin integrity and promoting mobility are core clinical competencies in nursing. Immobility, poor nutritional status, and inadequate hygiene are major risk factors for pressure injuries, which cause significant patient discomfort and increase healthcare costs. Dubai Health Authority (DHA) facilities monitor pressure injury rates as a key indicator of nursing care quality.

Skin Integrity and Risk Assessment

The skin is the body's first line of defense against pathogens. Nurses must routinely inspect the skin, especially over bony prominences.

• Braden Scale: A standardized tool used to predict pressure injury risk. It assesses six subscales:
  1. Sensory Perception: Ability to respond meaningfully to pressure-related discomfort.
  2. Moisture: Degree to which skin is exposed to moisture.
  3. Activity: Degree of physical activity.
  4. Mobility: Ability to change and control body position.
  5. Nutrition: Usual food intake pattern.
  6. Friction and Shear: Assistive requirements for moving and degree of sliding.
• Scoring: The total score ranges from 6 to 23.
  • 19 to 23: No risk.
  • 15 to 18: Mild risk.
  • 13 to 14: Moderate risk.
  • 10 to 12: High risk.
  • 9 or less: Severe risk.
  • Rule: A lower score indicates a higher risk of developing a pressure injury.

---

Pressure Injury Staging (NPIAP Guidelines)

Pressure injuries are localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from intense or prolonged pressure, or pressure in combination with shear.

---

Pressure Injury Prevention Bundle

Nurses must implement a comprehensive prevention plan for any patient identified as at-risk (Braden score ≤ 18):

1. Repositioning:
   • Turn bed-bound patients at least every 2 hours (using a turning schedule).
   • Reposition chair-bound patients at least every 15 to 30 minutes and instruct them to shift their weight every 15 minutes if able.
   • Use the 30-degree lateral position (side-lying at a 30-degree angle, supported by pillows) to avoid direct pressure on the trochanter (hip bone).
2. Skin Care and Moisture Management:
   • Inspect skin daily, focusing on bony prominences (sacrum, heels, trochanters, elbows, occiput).
   • Clean skin immediately after episodes of incontinence. Use a mild soap or no-rinse cleanser.
   • Apply moisture-barrier ointments (e.g., zinc oxide, petrolatum) to protect skin from moisture (urine, feces, sweat).
   • Do not massage reddened or bony areas, as this can cause deep tissue ischemia and worsen damage.
3. Friction and Shear Prevention:
   • Use a drawsheet (lift sheet) or friction-reducing transfer device to lift and move the patient in bed. Never drag the patient across the sheets.
   • Keep the head of the bed (HOB) elevated at 30 degrees or lower, unless medically contraindicated (e.g., during enteral feeding or respiratory distress), to prevent the patient from sliding down, which causes shearing forces on the sacrum.
4. Heel Offloading:
   • "Float" the heels by placing a pillow lengthwise under the calves, ensuring the heels do not touch the mattress. Avoid using donut-shaped cushions, as they restrict local blood flow.
5. Nutrition and Hydration:
   • Provide a high-protein, high-calorie diet with adequate fluids.
   • Monitor laboratory indicators of nutritional status, such as prealbumin (more sensitive to acute changes, half-life of 2 days) and albumin (chronic changes, half-life of 20 days).

---

Patient Positioning and Mobility Support

A nurse must understand clinical indications and techniques for various patient positions:

• Supine: Patient lies flat on their back. Elevate head on a pillow. Risk areas: occiput, sacrum, heels.
• Prone: Patient lies flat on their stomach. Head turned to one side. Promotes hip extension; often used in advanced respiratory management (e.g., ARDS - Acute Respiratory Distress Syndrome). Risk areas: forehead, chest, knees, toes.
• Fowler's: Head of the bed is elevated to 45 to 60 degrees. Used during meals, nasogastric tube insertion, and to promote chest expansion.
• Semi-Fowler's: Head of the bed is elevated to 30 to 45 degrees. Used to prevent aspiration during enteral feedings, reduce intracranial pressure, and promote lung expansion.
• High Fowler's: Head of the bed is elevated to 60 to 90 degrees. Used for patients experiencing severe respiratory distress (dyspnea) or during thoracic procedures.
• Sims' (Semi-prone): Patient lies on their side with the upper knee flexed and the lower arm behind them. Often used for rectal examinations, enema administration, and sleeping positions for pregnant women.
• Trendelenburg: The entire bed frame is tilted with the head of the bed down. Used to promote venous return in hypotensive patients or facilitate central venous catheter placement.

Range of Motion (ROM) Exercises

To prevent joint contractures and muscle atrophy in immobile patients:

• Active ROM: The patient performs the exercises independently with nurse supervision.
• Passive ROM: The nurse performs the movements for the patient without active patient participation.
• Guidelines: Perform exercises at least twice daily. Move each joint through its full range smoothly and gently. Stop the movement immediately if the patient reports pain or if muscle resistance is met. Support the joint by placing hands above and below it.

---

Professional DHA Exam Traps

• Albumin vs. Prealbumin: When asked about the most sensitive indicator of acute nutritional status for wound healing, choose prealbumin (half-life of 2 days) over albumin (half-life of 2-3 weeks).
• The Trochanter Risk: When positioning a patient laterally, do not position them directly on their hip (90-degree lateral). This concentrates pressure on the trochanter. Always position them at a 30-degree angle.
• Stable Heel Eschar: If a patient has a stable, dry, black eschar on the heel (without redness, fluctuance, or drainage), the correct nursing action is to leave it intact and float the heels. Debridement is contraindicated because the heel has poor vascularity.