2.5 Skin Care & Comfort
Key Takeaways
- Reposition residents who cannot move themselves at least every 2 hours, and shift weight in a wheelchair about every 15 minutes, to prevent pressure injuries.
- Pressure injuries form over bony prominences such as the sacrum, hips, heels, ankles, elbows, and back of the head.
- NPIAP Stage 1 is non-blanchable redness of intact skin; report any redness that does not fade after pressure is relieved.
- The Braden Scale rates pressure-injury risk on six subscales; a lower total score means higher risk (19-23 not at risk, 9 or below very high risk).
- Lift rather than drag to avoid shearing, keep linens clean, dry, and wrinkle-free, and assume a dying resident can still hear since hearing is the last sense to remain.
Pressure Injury Prevention
Quick Answer: A pressure injury (pressure ulcer or bedsore) is damage to the skin and underlying tissue caused by unrelieved pressure, usually over a bony area. The single most important prevention measure is repositioning the resident at least every two hours.
Pressure injuries form when constant pressure presses soft tissue between a bone and a surface, cutting off blood flow so the skin and tissue begin to die. They commonly develop over bony prominences:
- Sacrum (tailbone) and hips
- Heels and ankles
- Elbows and shoulder blades
- Back of the head and the ears
Three forces work together: pressure (sustained weight), shearing (skin pulled one way while tissue underneath moves another, as when a resident slides down in bed), and friction (skin rubbing against sheets). Residents at highest risk are those who are immobile, incontinent, poorly nourished, dehydrated, or have poor circulation. Because the CNA provides most hands-on care, the CNA is the team's front line for both preventing and spotting these injuries early.
NPIAP Pressure Injury Stages
The National Pressure Injury Advisory Panel (NPIAP) staging system describes how deep the damage goes. A CNA does not stage wounds (the nurse does), but knowing the stages helps the CNA describe and report what they see accurately.
| Stage | What you see |
|---|---|
| Stage 1 | Intact skin with non-blanchable redness (redness that does not turn white when pressed) |
| Stage 2 | Partial-thickness loss of skin; shallow open area or an intact or burst fluid-filled blister |
| Stage 3 | Full-thickness skin loss; fat (adipose) tissue is visible, but muscle and bone are not |
| Stage 4 | Full-thickness loss with exposed muscle, tendon, or bone |
| Unstageable | Base hidden by slough or eschar (dead tissue), so depth cannot be confirmed |
| Deep Tissue Injury | Persistent deep red, maroon, or purple intact or blistered skin |
The earliest sign, Stage 1, is redness that does not fade after pressure is relieved, especially over a bony area. Report it immediately so the team can intervene before the skin breaks.
Braden Scale and Repositioning Schedule
The Braden Scale is the most widely used tool to predict pressure-injury risk. The nurse scores six subscales, sensory perception, moisture, activity, mobility, nutrition, and friction/shear, and adds them for a total. A lower total means higher risk.
| Braden Total | Risk Level |
|---|---|
| 19-23 | Not at risk |
| 15-18 | At risk |
| 13-14 | Moderate risk |
| 10-12 | High risk |
| 9 or below | Very high risk |
The care plan turns that risk into action. Reposition on a regular schedule:
| Care Action | Frequency |
|---|---|
| Reposition in bed | At least every 2 hours |
| Shift weight in a wheelchair | About every 15 minutes |
| Check skin during care | Every shift and at each repositioning |
When repositioning, lift rather than drag the resident to avoid shearing; use a draw sheet and a partner for heavy residents. Keep linens clean, dry, and wrinkle-free, and use pillows so bony surfaces (knees, ankles, heels) do not press together. Pressure-relieving mattresses and heel cushions add protection.
Skin Observation and Comfort Measures
The CNA sees the resident's skin during daily care and is often the first to notice a problem. During bathing and repositioning, observe and report:
- Redness that does not fade after pressure is relieved (a possible Stage 1 injury)
- Broken skin, blisters, swelling, or open areas
- Bruises, rashes, or changes in skin color or temperature
- Dry, flaking skin or unusual moisture
Report these to the nurse right away; early reporting can stop a small problem from becoming a serious wound. To protect skin, keep it clean and dry, apply lotion to dry areas (but not between toes or on broken skin), and never massage a reddened bony area, which can worsen fragile tissue.
Comfort supports rest, healing, and quality of life. The CNA promotes comfort by repositioning for proper alignment, keeping the room at a comfortable temperature with reduced noise and light, providing clean dry linens, assisting with toileting and oral care, and offering reassurance. Always report unrelieved pain to the nurse, since the CNA does not give medication but does help identify the need for it.
End-of-Life Basics
Residents who are dying deserve comfort, dignity, and respect, and the CNA provides steady physical and emotional support:
- Continue gentle skin care, oral care (the mouth often becomes very dry), repositioning, and keeping the resident clean and comfortable
- Speak softly and assume the resident can still hear, since hearing is often the last sense to remain
- Provide privacy, allow family to be present, and honor cultural and religious wishes
- Support advance directives and the resident's documented choices, such as a Do Not Resuscitate order, and report changes to the nurse
- Recognize that grief is normal for the resident, family, and staff; listen, do not judge, and avoid clichés
Know the common signs that death is near, including decreased intake, cool mottled skin, irregular or noisy breathing, and reduced responsiveness, and report them. After death, provide respectful postmortem care as directed by facility policy, handling the body gently, following standard precautions, and maintaining privacy and dignity throughout.
How often should a bedbound resident who cannot move independently be repositioned to prevent pressure injuries?
While giving a bed bath, a CNA notices a reddened area over a resident's sacrum that does not turn white when pressed. How should the CNA respond?
On the Braden Scale, which total score indicates that a resident is at the highest (very high) risk for a pressure injury?
When caring for a resident who is near the end of life and appears unresponsive, why should the CNA continue to speak softly and explain care?