Skin Integrity and Pressure Injury Prevention

The Anatomy and Aging of Skin

The skin is the body's largest organ and its first line of defense against infection. It consists of the epidermis (outer layer), dermis (middle layer containing nerves and blood vessels), and subcutaneous tissue (inner fatty layer). As residents age, their skin undergoes significant changes. It becomes thinner, loses elasticity, and produces less oil, resulting in dryness and fragility. Subcutaneous fat diminishes, making the elderly more sensitive to temperature and significantly more vulnerable to skin tears and pressure injuries. LNAs must handle elderly skin with extreme care, avoiding any pulling, dragging, or rough scrubbing.

Understanding Pressure Injuries

A pressure injury (also known as a bedsore or decubitus ulcer) is localized damage to the skin and underlying soft tissue. It typically occurs over a bony prominence or is related to a medical or other device. The primary cause is pressure. When prolonged pressure is applied to the skin, it compresses the blood vessels, cutting off the blood supply to the tissue. This lack of blood flow is called ischemia. Without oxygen and nutrients, the cells quickly begin to die, leading to tissue necrosis (death) and the formation of an ulcer.

Pressure injuries are incredibly painful, prone to severe infection, and can be fatal. Preventing them is a massive priority in all New Hampshire healthcare facilities, as they are considered 'never events'—outcomes that are largely preventable with proper nursing care.

Identifying Bony Prominences

Pressure injuries most commonly occur over bony prominences—areas where the bone is close to the skin surface with little fat to cushion it. You must know these critical pressure points. Depending on how the resident is positioned, vulnerable areas include:

• Supine (on the back): Back of the head (occiput), shoulder blades (scapulae), elbows, sacrum (tailbone), and heels.
• Lateral (side-lying): Ears, sides of shoulders, hips (trochanters), knees, and ankles.
• Prone (on the stomach): Toes, knees, genitalia (in men), breasts (in women), and cheekbones.
• Sitting: Ischial tuberosities (the 'sit bones' in the buttocks), sacrum, and heels.

Preventing Friction and Shearing

In addition to direct pressure, friction and shearing are primary culprits in skin breakdown.

• Friction occurs when two surfaces rub together. For example, dragging a resident's heels across the bedsheets creates friction, which can strip away the delicate epidermis and cause skin tears.
• Shearing is a deeper, internal force. It occurs when the skin sticks to a surface (like the mattress) while the underlying bone and muscle slide in the opposite direction. A classic example is when the head of the bed is raised too high, causing the resident's skeleton to slide toward the foot of the bed while the skin of their back remains gripped by the sheets. This tears the blood vessels beneath the skin.

To prevent friction and shearing:

• Always use a draw sheet or slide board to lift and move a resident; never drag them.
• Keep the head of the bed elevated at 30 degrees or less, unless contraindicated by a feeding tube or respiratory issue, to prevent the resident from sliding down.
• Apply protective devices like heel protectors or elbow pads as outlined in the care plan.

Repositioning Schedules and Support Surfaces

The most effective way to prevent pressure injuries is regular turning and repositioning. The standard medical schedule requires bedbound residents to be repositioned at least every 2 hours (q2h). For residents who are chairbound or sitting in wheelchairs, the risk is even higher because pressure is concentrated on a smaller area; they must be prompted to shift their weight or be repositioned every 15 to 30 minutes.

When repositioning, use pillows to maintain the new position and protect bony prominences from touching each other (e.g., placing a pillow between the knees). A critical practice is 'floating the heels'—placing a pillow under the resident's calves so their heels are entirely suspended in the air, bearing no weight against the mattress.

Daily Skin Observation and Moisture Control

LNAs are the first line of defense in identifying early skin changes. You must inspect the resident's skin systematically during every bath, dressing change, and toileting assist.

The first sign of a pressure injury is a reddened area on fair skin, or a dark, purplish hue on dark skin, which does not turn white when you gently press it. This is called non-blanchable erythema.

CRITICAL RULE: If you observe a reddened area over a bony prominence, you must NEVER massage it. Massaging already compromised, ischemic tissue damages the fragile capillaries and accelerates deep tissue necrosis. Instead, relieve the pressure immediately by turning the resident off that side, and report the finding to the charge nurse right away.

Moisture from incontinence (urine or feces) drastically increases the risk of skin breakdown. Prolonged exposure causes the skin to soften and break down (maceration) and causes chemical burns (excoriation). Check incontinent residents frequently, change soiled briefs promptly, use gentle, pH-balanced cleansers rather than harsh soaps, pat the skin completely dry, and apply barrier creams only if delegated by the nursing staff. Clean, dry skin is resilient skin.