Skin Care and Pressure Injury Prevention

Skin Care and Pressure Injury Prevention

Skin is the body’s first barrier against infection. In Delaware nursing facilities, pressure injuries (also called pressure ulcers or bedsores in older materials) are closely watched by surveyors, families, and quality programs. CNAs spend more time at the bedside than almost any other team member, so observation during bathing, dressing, toileting, and repositioning is how most early skin problems are found. Domain III written items often ask what causes breakdown, how often to turn a resident, and which action is wrong when you see redness over a bony prominence.

How Pressure Injuries Develop

A pressure injury is localized damage to skin and/or underlying tissue, usually over a bony prominence, related to pressure or pressure combined with shear. Contributing forces include:

Residents at highest risk include those who are bedbound or chairbound, incontinent, underweight or overweight, sedated, have dementia and do not shift weight, or have existing vascular or neurologic disease.

Common Pressure Points

Memorize locations for exam scenarios and bedside checks:

• Supine: occiput (back of head), scapulae, elbows, sacrum/coccyx, heels
• Side-lying: ear, shoulder, ilium/hip, greater trochanter, knees (if touching), ankles/malleoli
• Prone (less common in LTC): cheeks, genitalia, knees, toes
• Sitting: ischial tuberosities (“sit bones”), spine against chair, heels if feet dangle poorly

Heels and sacrum are classic long-term care failure points. Float heels off the mattress with pillows under the calves (not directly under the Achilles in a way that creates new pressure) when the care plan directs heel offloading.

Turning and Repositioning Schedules

General teaching standards used on nurse aide exams:

• Reposition a dependent resident in bed at least every 2 hours, or more often if ordered
• Encourage or assist chair-bound residents to shift weight about every 15 minutes if able; full position change about every 1 hour with assistance as needed
• Follow the care plan exactly—some residents need q1h turns or specialty positioning after surgery
• Use a turn clock or assignment sheet so the whole team shares responsibility
• Maintain body alignment: head supported, spine straight, joints slightly flexed for comfort, bony prominences padded, call light in reach

When turning:

1. Explain what you will do; get help or a mechanical lift when the care plan requires it
2. Raise the bed; lock wheels; lower side rail on your working side per policy
3. Use a draw sheet; do not drag skin across linens
4. Place pillows to keep bony areas from touching each other (e.g., pillow between knees in side-lying)
5. Avoid positioning directly on an existing reddened area or wound when alternatives exist
6. Check skin while turning—this is assessment time, not only a logistics task

Document turns per facility policy and report if you cannot complete scheduled repositioning because of an emergency elsewhere—the nurse must know the gap.

Skin Inspection: What to Look For

During ADLs, look and gently observe (without probing wounds):

• Color changes: redness, purple/maroon discoloration (deep tissue injury concern), pallor, darkening on deeper skin tones (compare to surrounding skin—redness is harder to see; look for warmth, bogginess, or texture change)
• Non-blanchable erythema — redness that does not lighten briefly when pressed (early pressure injury warning on light skin)
• Breaks, blisters, abrasions, rashes, bruises, skin tears
• Warmth, coolness, swelling, drainage, odor
• Resident report of pain, itching, or burning over a pressure point

Report promptly—do not wait for end of shift if new

New non-blanchable redness, open areas, bruising of unknown origin, or suspected deep tissue injury should be verbally reported to the licensed nurse as soon as practical. Early nursing intervention (orders for dressings, surfaces, nutrition consults) prevents progression. Photographing wounds is a facility/policy and privacy issue—follow rules; never use a personal phone for resident wounds.

Never Massage Reddened Bony Prominences

This is a high-yield “always wrong” action on exams:

Do not massage reddened areas over bony prominences.

Older teaching sometimes promoted massage “to increase circulation.” Current pressure-injury prevention science treats massage of reddened bony sites as potentially damaging to already injured tissue. Gentle lotion on intact, non-reddened dry skin may be appropriate; massaging a red sacrum is not. If you see redness, offload pressure, keep the area clean and dry, and report.

Back rubs for comfort, when allowed, should avoid vigorous massage over pressure-damaged or reddened bony sites.

Moisture Management and Basic Skin Care

• Clean urine and stool immediately; prolonged contact causes incontinence-associated dermatitis that can progress to deeper injury
• Use mild cleansers; avoid harsh scrubbing
• Pat dry—especially skin folds, under breasts, and between toes (per foot-care rules)
• Apply barrier ointments only as directed on the care plan
• Change damp linens and gowns promptly
• Avoid plastic-backed incontinence products left in place too long without checks
• Encourage fluids and protein-rich intake as ordered—healing needs fuel

For skin tears common in elderly thin skin: support the flap per nursing direction, do not roughly tear tape off skin, and use gentle handling during transfers.

Support Surfaces and Devices

Facilities may assign:

• Pressure-reducing or pressure-relieving mattresses (foam, gel, air-loss, alternating pressure)
• Chair cushions designed for pressure redistribution
• Heel suspension boots, elbow protectors, bed cradles to keep linens off toes
• Draw sheets and slide boards to reduce friction/shear

Critical teaching point: a specialty mattress is not a free pass to skip turning unless a specific medical order and care plan say otherwise. Devices fail when misused—gel cushions slid to the side, air mattresses unplugged, or heels still resting hard on the bed.

CNAs do not independently order mattresses; they implement the care plan, report bottoming-out of cushions, and keep tubing and electrical cords safe.

Linking Skin Care to Other Personal Care Skills

Bathing is your full-body skin survey. Perineal care prevents moisture injury. Dressing and transfers are when shear happens if you drag. Bedpan and incontinence care, covered next, are moisture control in action. On Delaware skills day, Indirect Care scoring still expects you to protect skin: smooth wrinkles under the resident, dry after peri care, and avoid trauma during movement.

Exam Scenarios to Rehearse

1. Resident left sitting in a wet brief for hours → clean, dry, barrier if ordered, report skin condition, and address why checks failed.
2. Red non-blanchable area on coccyx → do not massage; reposition off the area; report to nurse immediately.
3. Family asks you to massage lotion hard into a red hip “for circulation” → explain you will keep the area protected and notify the nurse; do not massage.
4. Turn schedule missed during a code on the unit → as soon as able, turn the resident and tell the nurse about the delay.

Professional Mindset

Pressure injury prevention is team-based: nursing assessment, dietary support, therapy for mobility, and CNA execution of turns and hygiene. Your reliability on the two-hour clock and your honesty about skin findings protect residents from painful, expensive, and sometimes fatal complications. On the Prometric exam, choose the answer that offloads pressure, controls moisture, reports early, and never massages reddened bony prominences.