4.1 Skin Care & Pressure-Injury Prevention

Why Skin Care Dominates Basic Nursing

On the Kentucky State Registered Nurse Aide (SRNA) written exam, skin integrity and pressure-injury prevention sit inside the Basic Nursing and Disease Process categories, which together account for roughly 19 of the 75 scored questions on the KCTCS blueprint. Skin breakdown is also one of the most heavily surveyed quality indicators for the Kentucky Cabinet for Health and Family Services (CHFS), which inspects nursing facilities. Because SRNAs bathe, reposition, and dress residents every shift, they see skin more than any nurse or physician — so the exam expects you to detect early changes and report them promptly.

The SRNA's Scope: Observe and Report

The single most tested principle is scope of practice. SRNAs observe and report skin changes; nurses assess, stage, and treat. You never stage a wound, change a dressing, apply medicated cream, or massage a reddened area. When you notice a change, you document objective facts — location, approximate size, color, drainage (amount, color, odor), and pain — and report to the charge nurse immediately. A common exam trap is a saturated dressing: the correct action is to notify the nurse (saturation may signal infection or hemorrhage), NOT to reinforce it with more gauze or change it yourself.

Observing Skin & Reporting Changes

Inspect skin during every bath, brief change, reposition, and transfer. Report these findings to the nurse immediately:

• Non-blanchable redness over a bony prominence (does not turn white when pressed)
• Breaks, blisters, tears, bruises, or open areas
• Warmth, swelling, or hardness compared with surrounding skin
• Rashes, white patches, or moist/macerated skin
• Yellow, green, or foul-smelling drainage
• Pale, gray, purple, or maroon discoloration

A classic scenario: during a bed bath you find a reddened area over the sacrum that does not blanch. Correct action — stop massaging, report to the nurse immediately, and document. Massaging non-blanchable redness worsens the tissue damage by further reducing circulation.

Pressure-Injury Stages (NPIAP)

Kentucky facilities use the National Pressure Injury Advisory Panel (NPIAP) staging system. You must recognize the stages to report accurately, even though you never assign a stage yourself.

Remember: Stage 1 is intact skin (redness only), while Stage 2 is the first stage with an open wound or blister. Confusing these two is a frequent exam error.

Pressure Points & Repositioning

Pressure injuries form where bony prominences press soft tissue against a surface, cutting off blood flow. The high-risk points depend on position:

• Supine (on back): sacrum, coccyx, heels, elbows, shoulder blades, back of head (occiput)
• Side-lying: hip (greater trochanter), outer ankle (malleolus), knee, ear, shoulder
• Sitting: ischial tuberosities (sit bones), tailbone, heels

The repositioning standard is a top-tested number: reposition bedbound residents at least every 2 hours, and chair-bound residents at least every 1 hour (encourage able residents to shift weight every 15 minutes). When side-lying, use a 30-degree lateral tilt — NOT a full 90-degree side position, which puts the whole body weight on the trochanter. Place a pillow behind the back to hold the angle and a pillow between the knees to keep the ankles and knees from grinding together. For heels, float them completely off the mattress by placing a pillow under the calves — never under the heels themselves (that creates a focal pressure point), and never use donut-shaped rings (they increase edge pressure and cut circulation).

Keeping Skin Clean & Dry: Friction vs. Shear

Moisture, friction, and shear all accelerate breakdown. Friction is skin rubbing against a surface (dragging a resident across a sheet). Shear is when the skin stays still but the deeper tissue slides — for example, when the head of the bed is raised above 30 degrees and the resident slides down, the skin sticks to the sheet while the sacrum slides underneath. Prevent both by lifting rather than dragging (use a draw sheet with two aides), keeping the head of bed at or below 30 degrees when possible, and keeping sheets wrinkle-free.

Manage moisture aggressively. Incontinent residents must be checked and changed at least every 2 hours and after every episode; prolonged contact with urine or stool causes incontinence-associated dermatitis (IAD), a precursor to pressure injury. Clean gently front-to-back with warm water and a mild cleanser, pat (do not rub) dry, and report any redness — but do not apply a barrier cream without a nurse's order.

Identifying At-Risk Residents

The resident at highest risk combines multiple factors: advanced age, immobility (bedbound), incontinence (moisture), malnutrition (poor healing), and diabetes (impaired circulation and sensation). Kentucky facilities screen all residents with a validated tool — the Braden Scale — at admission and regularly thereafter. The SRNA supports the care plan by repositioning on schedule, keeping skin clean and dry, encouraging adequate nutrition and fluids, and reporting the earliest signs of breakdown before a Stage 1 becomes a Stage 3.