CARE: SKIN INTEGRITY (PRESSURE INJURIES AND CONTACT DERMATITIS)

pressure injury

Skin and/or underlying tissue damage caused by prolonged pressure or pressure combined with shear.

commonsites for pressure injuries

Sacrum

Heels

Trochanters

Ischial tuberosities

Elbows

Occiput

what may pressure wounds present as

intact skin, an open wound, deep discoloration, pain, or device-shaped injury.

when are pressure injuries preventable

when risk is identified early and prevention is consistent

pressure

Tissue compressed between bone and surface

• EX: sacral injury from bedrest

nursing prevention for pressure

Reposition, offload, support surfaces

shear

Skin stays in place while deeper tissue slides

• EX: sliding down in bed with HOB elevated

nursing prevention for shear

Lift, don’t drag; limit HOB when appropriate

friction

skin rubs against surface

• elbows/heels rubbing on linens

nursing preventions for friction

Protective dressings, smooth linens, careful transfers

moisture

Skin becomes overhydrated and fragile

• EX: incontinence- associated dermatitis

nursing prevention for moisture

Cleanse, dry, barrier cream, toileting plan

who is vulnerable for pressure injuries

Immobility: unable to shift weight

Poor perfusion : PVD, shock, diabetes

Altered sensation: spinal cord injury, neuropathy

Moisture: incontinence, diaphoresis

Poor nutrition: low protein/calories, dehydration

Age/frailty: thin skin, reduced reserve

Medical devices: oxygen tubing, masks, casts

Medications: sedatives, vasopressors, steroids

what does the braden scale do

Identifies risk level and guides prevention bundles for pressure injuroes

for the braden scale the lower the score

the higher the risk

braden scale categories

Sensory perception

Moisture

Activity

Mobility

Nutrition

Friction/shear

what does the braden score not replace

Focused skin assessment

Clinical judgment

Device checks

Patient-specific interventions

when is a risk score useful

only if it triggers appropriate prevention

wound assessment components

Location: Anatomic site; relationship to bony prominence or device

Size: Length × width × depth in cm

Wound bed: Granulation, epithelialization, slough, eschar

Drainage: Amount, color, consistency, odor

Edges/margins: Attached, rolled/epibole, undermining, maceration

Periwound skin: Erythema, warmth, induration, moisture, pain

Tunneling/undermining: Clock method and depth

wound assessment what to look for

Persistent color change

Purple, blue, gray, or ashen tone

Localized shiny or taut skin

wound assessment what should you feel

Temperature difference

Boggy or firm tissue

Swelling or induration

what should you ask the patient during a wound assessment

Pain

Burning

Tingling

Change in sensation

Stage 1 pressure ulcer key finding

Nonblanchable erythema of intact skin

stage 1 pressure ulcer what you see

Skin intact; may show temperature, sensation, or firmness changes

Stage 2 pressure ulcer key finding

Partial-thickness skin loss with exposed dermis

Stage 2 pressure ulcer what you see

Pink/red moist wound bed or serum-filled blister; no adipose tissue

Stage 3 pressure ulcer key finding

full thickness skin loss

Stage 3 pressure ulcer what you see

Adipose may be visible; slough/eschar may appear; no exposed bone/tendon/muscle

Stage 4 pressure ulcer key finding

Full-thickness skin and tissue loss

Stage 4 pressure ulcer what you see

Exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone

unstageable pressure ulcer key finding

depth is obscured

unstageable pressure ulcer what you see

Slough or eschar prevents visualization of wound base

deep tissue pressure injury key finding

Persistent deep red/maroon/purple discoloration

deep tissue pressure injury what you see

Intact or non-intact skin; damage begins in deeper tissue

pressure injury staging decision tree

Medical Device-Related Pressure injury

Caused by diagnostic or therapeutic devices.

Shape often matches device.

Stage using usual staging system

mucosal membrane pressure injury

Occurs on mucous membranes from device use.

Examples: ET tube, NG tube, urinary catheter.

Cannot be staged

STOP Stable Heel Eschar

Dry, adherent, intact eschar on ischemic heel/limb is usually left intact unless ordered otherwise.

device related injuries are

preventable

• inspect under and around devices

Stage 1 Pressure Injury: Non- Blanchable Erythema of Intact Skin (NPIAP)

• Intact skin with a localized area of non-blanchable erythema.

• May be preceded by blanchable erythema or by changes in sensation, temperature, or firmness

• Does not include purple or maroon discoloration

• May appear differently in darkly pigmented skin.

Stage 2 Pressure Injury: Partial-Thickness Skin Loss with Exposed Dermis (NPIAP)

• Partial thickness loss of skin with exposed dermis

• Wound bed is pink or red and moist

• May occur as an intact or ruptured serum filled blister

• Adipose or deeper tissues are not visible

Stage 3 Pressure Injury: Full-Thickness Skin Loss (NPIAP)

• Full thickness loss of skin

• Granulation tissue and epibole often present

• Slough and or eschar may visible

• May be undermining or tunneling

• Depth varies by anatomic location and degree of adiposity

• The injury can extend down to, but not through underlying fascia; there is no exposed muscle or bone.

Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss (NPIAP)

• Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound.

• Slough and or eschar may be visible

• Epibole, undermining, and or tunneling may occur

• Depth varies by anatomic location

Pressure Injury Prevention Bundle

Risk assess: Braden + clinical judgment

Inspect skin: head-to-toe + under devices

Reposition: turn schedule; offload heels

Manage moisture: cleanse, dry, barrier product

Reduce shear: lift, don't drag; HOB mindful

Support surfaces: mattress/chair cushions

Nutrition: protein, calories, hydration

Mobilize: ambulate/ROM as able

• These preventions work best as a bundle not individual interventions

What not to do to a pressure injury

✕ Do not massage bony prominences: May damage fragile tissue.

✕ Do not drag patients across linens: Increases friction and shear.

✕ Do not use donut cushions: Can concentrate pressure.

✕ Do not leave heels resting on bed: Offload heels completely.

✕ Do not ignore device pressure: Assess under tubing, masks, braces, collars.

✕ Do not remove stable heel eschar: Unless ordered/clinically indicated

why is protein and calories needed for for pressure injuries

Needed for tissue repair, immune function, and collagen synthesis.

what is hydration needed for pressure injuries

Supports perfusion and skin turgor

what to monitor during hydration

Monitor intake, output, and contraindications

what micronutrients are needed for pressure injuries

Vitamin C, zinc, copper, vitamin A may be considered when deficient or ordered.

when is wound healing impaired

when perfusion, nutrition, or infection control is inadequate

wound care principles: think TIME

TIME

TIME stand for

Tissue

infection/inflammation

mositure balance

edge

tissue clincial question

Is nonviable tissue present?

tissue nursing action

Debridement when appropriate; protect stable heel eschar

infection/inflammation clinical question

Are there local or systemic infection cues?

infection/inflammation nursing action

Culture/antibiotics if ordered; report fever, odor, purulent drainage

moisture balance clinical question

Is the wound too dry or too wet?

moisture balance nursing action

Select dressing to maintain moist healing and protect periwound

Edge clincial question

are edges advancing

edge nursing action

Monitor size/depth, epibole, undermining; consult WOC nurse

dry wound bed dressing goal

Add/maintain moisture as ordered

heavy exudate wound dressing goal

Absorb drainage and protect periwound skin

Fragile surrounding skin dressing

Use gentle adhesive or non-adhesive options

tunneling/dead space wound goal

Fill dead space without overpacking

infection concern dressing

Assess/report; antimicrobial dressing may be ordered

high risk bony area dressing

Protective foam may reduce friction/shear

When to consult WOC nursing

Unstageable or deep tissue pressure injury

Stage 3 or Stage 4 pressure injury

Rapidly worsening wound

Complex dressing needs

Heavy exudate, odor, tunneling, or undermining

Concern for infection or delayed healing

Medical device-related injury

Need for patient/family education on wound care

team members for WOC nursing

WOC nurse, provider, dietitian, PT/OT, case management, patient/family

WOC nursing prioirty

Escalate early. Waiting often increases wound severity and cost

Complications of Pressure Injury

Local infection: increased pain, erythema, drainage, odor

Cellulitis: spreading warmth/redness/swelling

Osteomyelitis: bone involvement, delayed healing

Sepsis: fever, tachycardia, hypotension, altered LOC

Pain/QOL: sleep disruption, mobility limits, distress

Cost/LOS: longer hospitalization and more intensive care

systemic infection cues from pressure injuires require

prompt escalation

Irritant Contact Dermatitis: mechanism

Direct skin damage from irritant

Irritant Contact Dermatitis: common triggers

Soaps, detergents, chemicals, frequent hand hygiene

Irritant Contact Dermatitis: timing

Can occur quickly after exposure

Irritant Contact Dermatitis: symptoms

Burning, pain, redness, dryness/fissures

Irritant Contact Dermatitis: mangament

Remove irritant, protect barrier, moisturize

Allergic Contact Dermatitis: mechanism

Delayed immune hypersensitivity reaction

Allergic Contact Dermatitis: commn triggers

Latex, nickel, poison ivy, adhesives, fragrances

Allergic Contact Dermatitis: timing

Often delayed 24–72 hr after exposure

Allergic Contact Dermatitis: symtoms

Intense itching, erythema, vesicles, oozing/crusting

Allergic Contact Dermatitis: management

Avoid allergen, topical steroids if ordered, antihistamines for itching

what are you doing when doing an assessment of contact dermitisis

find the exposure pattern

contact dermatitis history

New soaps, detergents, gloves, plants, metals, adhesives, workplace chemicals, skin products.

contact dermatitis distribution

Where is the rash?

Does it match a device, jewelry, glove, plant exposure, or topical product

contact dermatitis complications

Scratching can lead to secondary infection.

Assess for drainage, warmth, fever,

spreading erythema.

Contact Dermatitis Management

remove

relieve

treat

protect

Contact Dermatitis Management: remove

Stop exposure to irritant/allergen

Contact Dermatitis Management: relieve

Cool wet compresses, reduce itching

Contact Dermatitis Management: treat

Topical corticosteroid or antihistamine if ordered

Contact Dermatitis Management: protect

Barrier creams, gloves, trigger avoidance

contact dermatitis patient teaching

Avoid scratching. Keep nails short. Report infection signs.

Contact Dermatitis: safety→ allergy

Latex allergy requires clear documentation and latex-free supplies.