skin Disorders

Pressure Ulcers (Pressure Injuries)

Definition

• A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or caused by medical devices.

• It ranges from minor skin damage to large, open ulcers and can be painful.

• The injury results from intense or prolonged pressure, shear, or friction.

• Factors affecting tissue tolerance:

  • Environmental conditions

  • Nutritional status

  • Perfusion (blood supply) to the area

  • Comorbidities (e.g., diabetes, vascular disease)

Pathophysiology

• Pressure reduces blood flow to capillaries, leading to impaired cell metabolism.

• Prolonged pressure (even within 20 to 40 minutes) can result in tissue anoxia (lack of oxygen) and skin breakdown.

• Friction: Occurs when the skin rubs against another surface (e.g., pulling rather than lifting someone in bed).

• Shear: Happens when skin stays stationary while underlying tissues shift, causing damage (e.g., sliding down in bed).

Common Pressure Points

• Areas with less tissue coverage over bones are more prone to ulcers:

  • Sacrum (lower back)

  • Heels

  • Elbows

  • Hips

  • Shoulder blades

  • Back of the head

  • Ankles

Risk Factors for Pressure Ulcers

Certain individuals are at higher risk:

1. Elderly: Thinner, less elastic skin makes them prone to breakdown.

2. Malnourished: Lack of muscle and fat increases susceptibility.

3. Incontinence: Prolonged moisture weakens skin integrity.

4. Immobility: Individuals who are bedridden or paralyzed are unable to reposition themselves.

5. Impaired circulation: Conditions like diabetes and peripheral vascular disease reduce blood flow to tissues.

Prevention of Pressure Ulcers

Best Practice: Prevention Strategies

• Skin Assessment:

  • Check daily for redness, breakdown, or blanching.

  • Avoid massaging red areas as this can worsen damage.

• Keep skin clean and dry:

  • Clean incontinence immediately.

  • Use moisture barriers if needed.

  • Apply lubricants to prevent dryness.

• Repositioning & Weight Shifting:

  • In bed: Reposition every 2 hours.

  • In a chair: Shift weight every 15 minutes.

  • Keep heels elevated off the bed.

• Pressure Redistribution:

  • Use pressure-relieving mattresses and cushions.

  • Pad and protect bony prominences.

  • Use a lift sheet instead of pulling to prevent shearing.

• Nutrition & Hydration:

  • Protein is essential for wound healing.

  • Malnutrition can slow down healing.

Braden Scale: Assessing Pressure Ulcer Risk

• Tool used in clinical settings to determine the risk of developing a pressure ulcer.

• Lower scores = Higher risk.

• Evaluates six factors:

  1. Sensory Perception – Ability to respond to discomfort.

  2. Moisture – Exposure to moisture (e.g., incontinence).

  3. Activity – Degree of physical movement.

  4. Mobility – Ability to change positions.

  5. Nutrition – Quality of dietary intake.

  6. Friction & Shear – Likelihood of skin damage from movement.

Signs & Stages of Pressure Ulcers

Early Signs:

• Redness that does not blanch (stays red when pressed).

• Pain at the site.

• Open ulcerated areas.

• Necrotic (black) tissue – indicates dead tissue.

• Slough (yellow tissue) – needs removal for healing.

Stages of Pressure Ulcers

1. Stage 1:

   • Non-blanchable red area.

   • Intact skin, may feel warm or firm.

2. Stage 2:

   • Partial thickness skin loss.

   • May appear as blister (intact or ruptured).

   • Pink, red, moist wound bed.

3. Stage 3:

   • Full-thickness skin loss.

   • Visible fat tissue.

   • Granulation tissue, slough, or eschar may be present.

4. Stage 4:

   • Full-thickness skin and tissue loss.

   • Exposed muscle, tendon, or bone.

   • High risk of infection.

5. Unstageable:

   • Depth unknown due to slough or eschar covering the wound.

   • Requires debridement (removal of dead tissue).

Treatment & Management

General Wound Care

• Cleaning & Debridement:

  • Remove necrotic tissue (eschar, slough).

  • Use antimicrobial dressings if infection is present.

• Dressings (Per Physician’s Orders):

  • Foam dressings: Absorb drainage.

  • Hydrocolloids: Aid in autolytic debridement.

  • Hydrogels: Maintain moisture.

  • Negative pressure wound therapy (vacuum-assisted closure):

    • Removes drainage.

    • Increases circulation.

    • Speeds up healing.

• Removing Pressure Source:

  • Use heel protectors or pillows to relieve pressure.

  • Reposition frequently.

Other Skin Conditions

Dermatitis (Inflammation of the Skin)

• Causes:

  • Allergic reactions (detergents, perfumes).

  • Irritants (chemicals, medications).

  • Atopic dermatitis (eczema) – hereditary.

  • Stress.

• Symptoms:

  • Red, itchy lesions that may ooze.

• Treatment:

  • Avoid triggers.

  • Topical corticosteroids to reduce inflammation.

Psoriasis

• Chronic inflammatory disorder.

• Skin cells shed every 4-5 days (instead of 27 days).

• Symptoms:

  • Silvery plaques and scales.

  • Severe itching can lead to infections.

• Treatment:

  • Daily baths with soft brushes to remove scales.

  • Corticosteroids.

  • Topical medications.

Herpes

• Viral infection stored in nerve ganglia.

• HSV-1: Cold sores (above the waist).

• HSV-2: Genital herpes (below the waist).

• Shingles (Herpes Zoster):

  • Reactivation of varicella zoster (chickenpox).

  • Painful vesicles following a nerve pathway.

  • Treatment: Acyclovir within 72 hours of symptoms.

Fungal Infections

• Candidiasis (Thrush) – Oral fungal infection.

• Tinea (Ringworm):

  • Tinea pedis (Athlete's foot).

  • Tinea capitis (Scalp).

  • Tinea corporis (Body).

  • Tinea cruris (Jock itch).

• Treatment:

  • Antifungal creams or oral medications.

  • Keep skin dry.

Pediculosis (Lice)

• Direct contact transmission.

• Types:

  • Capitis (head lice).

  • Corporis (body lice).

  • Pubis (crabs).

• Treatment:

  • Lice shampoos (pediculicides).

  • Environmental cleaning (hot water laundry, vacuuming, bagging items for 10 days).

Scabies (Mites)

• Parasitic infection causing severe itching.

• Direct contact transmission.

• Treatment:

  • Topical scabicides.

  • Wash bedding, clothing, and pets.