Section 3.3: Observing and Reporting Skin Conditions & Wound Prevention
Key Takeaways
- Pressure injuries are caused by unrelieved pressure over bony prominences, resulting in ischemia, and are categorized into four main stages based on tissue depth.
- A Stage 1 pressure injury is characterized by non-blanchable erythema of intact skin, which must never be massaged as it worsens tissue damage.
- Essential prevention strategies include repositioning bedbound residents every 2 hours, using friction-reducing slide sheets to prevent shearing, keeping skin clean and dry, and floating heels.
Observing and Reporting Skin Conditions & Wound Prevention
Maintaining skin integrity is one of the most critical aspects of resident care in long-term care facilities. The skin is the body's first line of defense against infection. Under both federal regulations (OBRA 1987) and Iowa Administrative Code (IAC) 441 Chapter 81, facilities are heavily monitored on their ability to prevent and manage pressure injuries. A pressure injury (formerly called a pressure ulcer, bedsore, or decubitus ulcer) that develops while a resident is in a facility can be cited as a serious regulatory violation and is considered a key quality-of-care indicator. Certified Nursing Assistants (CNAs) play a pivotal role in preventing these injuries through daily observation, skin care, and repositioning.
Pathophysiology of Pressure Injuries
A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence, as a result of intense or prolonged pressure, or pressure in combination with shear.
- Ischemia: When a resident remains in one position for too long, the weight of the body compresses the blood vessels between the bone and the external surface (such as a bed or chair). This cuts off the supply of oxygen and nutrients to the tissues, leading to tissue ischemia (restricted blood flow). If the pressure is not relieved, the tissue dies (necrosis), resulting in a pressure injury.
- Bony Prominences (Pressure Points): These are areas where the bone lies close to the skin surface. The most common sites for pressure injuries include:
- Back-lying (Supine): Back of the head (occiput), shoulder blades (scapulae), elbows, sacrum, and heels.
- Side-lying (Lateral): Ear, side of the shoulder, hip (greater trochanter), knees (medial and lateral condyles), and ankles (malleoli).
- Sitting (Fowler's/Chair): Shoulder blades, sacrum/coccyx, ischial tuberosities (sitting bones), and heels.
Staging of Pressure Injuries
Pressure injuries are classified into stages based on the depth of tissue damage:
| Stage | Clinical Description | Visual Presentation |
|---|---|---|
| Stage 1 | Non-blanchable erythema of intact skin. The skin is not broken, but it is red or discolored. When you press on the area with your finger, it does not turn white (blanch). In dark-skinned residents, the area may appear purple, dark brown, or ash-gray and may feel warmer, cooler, or firmer than surrounding tissue. | Intact red skin, does not fade when pressed. |
| Stage 2 | Partial-thickness skin loss with exposed dermis. The injury involves the epidermis (outer layer) and dermis (second layer). It looks like a shallow open ulcer or a serum-filled blister. The wound bed is pink, red, and moist. | Shallow pink crater, ruptured or intact blister. |
| Stage 3 | Full-thickness skin loss. The injury extends through the dermis into the subcutaneous tissue (fat layer). Subcutaneous fat is visible in the ulcer, but muscle, tendon, ligament, or bone are not exposed. There may be tunneling or undermining (tissue destruction under the wound edges). | Deep crater showing yellow fat tissue. |
| Stage 4 | Full-thickness skin and tissue loss. The injury extends through all skin layers, exposing underlying muscle, tendon, ligament, cartilage, or bone. Osteomyelitis (bone infection) is a high risk. | Deep wound with exposed bone, muscle, or tendon. |
| Unstageable | Obscured full-thickness skin and tissue loss. The depth of the injury cannot be determined because it is completely covered by slough (yellow, tan, green, or brown dead tissue) or eschar (black or brown leathery dead tissue). | Black, leathery cover or yellow slough hiding wound bed. |
Risk Factors for Pressure Injuries
Understanding which residents are at high risk allows CNAs to implement targeted preventive interventions. Key risk factors include:
- Immobility: Residents who cannot move or reposition themselves in bed or a wheelchair.
- Incontinence (Moisture): Constant exposure to urine and feces weakens the skin (maceration) and makes it more susceptible to breakdown.
- Poor Nutrition and Dehydration: Inadequate protein and fluid intake impairs skin health and delays tissue repair.
- Friction and Shearing:
- Friction: The rubbing of one surface against another (e.g., skin dragging across a sheet).
- Shearing: Occurs when the skin remains stationary against a surface (like a bed sheet) while the underlying muscles and bones slide in the direction of body movement (e.g., when a resident slides down in bed). This stretches and tears the delicate capillaries supplying the skin.
- Cognitive Impairment: Residents who cannot feel discomfort or communicate the need to change positions.
Prevention Strategies: The CNA's Core Responsibilities
Prevention is far more effective than treatment. CNAs must execute the following evidence-based prevention measures:
- Repositioning Schedules:
- In Bed: Reposition residents at least every 2 hours (or more frequently if indicated in the care plan). Use a turn schedule (e.g., left side, back, right side). Use the 30-degree lateral position to avoid direct pressure on the hip bones (greater trochanters).
- In a Wheelchair: Reposition residents at least every 1 hour. Encourage or assist cognitively intact residents to shift their weight every 15 minutes.
- Safe Handling to Prevent Friction and Shearing:
- Never drag a resident across the sheets when moving them up in bed. Always use a draw sheet or friction-reducing slide sheet.
- Keep the head of the bed (HOB) at 30 degrees or lower unless contraindicated (such as during meals or tube feedings) to prevent the resident from sliding down and causing shear.
- Skin Care and Moisture Management:
- Inspect the skin daily, especially during bathing and perineal care.
- Wash skin gently with mild, pH-balanced soap and warm water. Avoid hot water, which dries the skin.
- Keep the skin clean and dry. Apply moisture barrier creams to the perineum of incontinent residents to protect against urine and stool.
- Never massage reddened or pale bony prominences. Massaging these areas breaks down the underlying capillaries and accelerates the formation of a pressure injury.
- Protective Devices:
- Float the Heels: Place a pillow under the resident’s calves to lift the heels completely off the mattress. Do not place the pillow directly under the heels.
- Use pressure-relieving mattresses, chair pads, and heel/elbow protectors as ordered in the care plan.
Observing and Reporting Skin Changes
During every resident contact, perform a visual scan of the skin. Report the following immediately to the supervising nurse:
- Any new redness, discoloration, or pale spots over bony prominences.
- Skin that feels unusually warm, cold, hard, or soft.
- Blisters, tears, scrapes, or open wounds.
- Changes in existing wounds, such as increased drainage, foul odor, or spreading redness.
- Complaining of pain or burning over a pressure point.
A CNA notices a reddened, intact area on a resident's sacrum during bathing. When the CNA presses on the area, it does not turn white. What stage of pressure injury does this represent?
To prevent pressure injuries for a resident who is bedbound, what is the most appropriate action for the CNA to take?
Which of the following describes a Stage 2 pressure injury?