Skin Care

Recommendations

Identify and Treat the Cause
1 Identify patients lacking protective sensation or having reduced ability to perceive or act on pain sensations, and implement an appropriate positioning or turning schedule. Level of Evidence
Not Assessed
2 Assess nutritional and swallowing status and implement corrective approaches where necessary. Level of Evidence
Not Assessed


Address Patient-Centered Concerns
3 Manage pain, preserve quality of life and assess psychosocial needs Level of Evidence
Not Assessed


Provide Local Wound care
4 Protect the integrity of the skin by ensuring adequate hydration, using gentle cleansers, applying moisturizers and using protective barriers or padding to minimize friction. Level of Evidence
Not Assessed
5 Minimize skin exposure to excessive moisture through effective continence management and use of protective barriers and moisture-absorbing products. Level of Evidence
Not Assessed
6 Consult a physician for assessment and treatment of skin irritation that does not improve with appropriate skin care strategies. Level of Evidence
Not Assessed
7 Introduce adjunctive modalities or biologically active dressings where appropriate, such as in cases with edge effects. Level of Evidence
Not Assessed


Provide Organizational Support
8 Empower and educate an interprofessional team to provide care to patients’ skin Level of Evidence
Not Assessed


Background

In patients at risk of pressure ulcers, several factors are important in the maintenance of skin integrity. These include intact sensation, adequate nutrition, maintenance of stratum corneum hydration and protection from excessive moisture.

Loss of sensation, due to spinal cord injuries, neuropathy or disease, prevents identification of potentially dangerous sustained pressure that would normally cause a change in position. Use of sedatives and analgesics may reduce pain perception and prevent an effective repositioning response. Absent or decreased sensation must be identified and appropriate repositioning or turning schedules implemented.

Adequate nutrition, including hydration, is critical to maintain skin integrity and prevent pressure ulcer development. A detailed nutritional and swallowing assessment should identify factors associated with impaired nutrition. Lack of vitamins and trace elements, impaired nutrition and reduced nutritional intake have all been associated with increased risk of pressure ulcers. In critically ill patients, nutritional supplementation decreases the risk of pressure ulcer development.

Maintenance of stratum corneum hydration protects the skin against mechanical injury. Adequate fluid intake is necessary, and maintenance of appropriate environmental temperature and humidity supports this goal. An individualized bathing schedule and cleansing as soon as possible after incontinent episodes can prevent chemical irritation of the skin. An individualized bathing schedule using a mild pH-balanced cleanser and warm, not hot, water can prevent drying and irritation of the skin. Moisturizers should be used regularly on dry skin and protective barriers or padding on skin that may be exposed to friction.

Wet or moist skin has increased fragility, a decreased ability to withstand friction and tearing, a tendency to adhere to bed linens, and an increased susceptibility to irritation, rashes and infection. It is therefore important to minimize skin exposure to excessive moisture. Effective continence management is essential to skin care. Collection devices or pouching systems may help to manage incontinence. When the source of moisture cannot be controlled, protective barriers and moisture-absorbing products are recommended. They should be changed once they are saturated, and care should be taken to ensure that they do not interfere with the effects of a pressure-redistributing system. Use of cotton bed linens and frequent changes are recommended to reduce moisture from perspiration. Persistence of skin irritation despite these measures should prompt a consultation with the physician for assessment and topical treatment.

References

Essential Publications
1 Topical Skin Care Quality Indicator
 Type: Systematic review
Hodgkinson B, Nay R, Wilson J (2007) A systematic review of topical skin care in aged care facilities. Journal of Clinical Nursing 16, 129-136.
This systematic review of systematic reviews, RCTs, and non-randomized controlled studies was conducted to determine the effectiveness of topical skin care interventions for residents of aged care facilities by examining the incidence of adverse skin conditions such as rash, skin irritation, haematoma or tears, and by patient satisfaction. Since the interventions and outcomes measured in the studies varied, the results were not combined but one or more individual studies were reported.


Enablers for practice

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