Version 1.0 – 17 January2018 (Review date 2020)

Maintaining Skin Integrity

and

Preventing Pressure Ulcers

Information for Nursing Care Homes

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Introduction to using this resource folder

This folder contains comprehensive information about the assessment, monitoring and

maintenance of skin integrity for care home residents. The focus is on prevention of skin

damage but also includes what to consider if the skin is broken. Where available, it includes

National evidence-based guidelines.

This folder contains information for registered nurses including ‘top tips’ to ensure your

residents are protected from skin breakdown. All care home staff should have training on

how to prevent pressure ulcers and this guide contains information that can support staff

training. Registered nurses should have training in wound management and work within their

sphere of competence (NMC 2015).

This resource folder has been developed by the Sutton Homes of Care Vanguard. The

contents of this folder represent best practice in this area of care; however, the safe and

effective management of residents’ needs remains the legal responsibility of the care

home.

Contents Page

1.0 The Skin

Why is the skin important?

What happens to the skin as we get older?

What causes damage to the skin?

3 3 4

2.0

Pressure ulcers

What is a pressure ulcer?

How do I know if my resident is at risk of pressure ulcers?

Interpreting the Waterlow score- what to do next

4 5 6

3.0 Minimising risk using SSKIN prevention guidance 3.1 Surface: Support surfaces including mattresses and cushions 3.2 Skin: How to keep the skin healthy, how to inspect the skin and what to look for 3.3 Keep moving: Supporting your residents to change position 3.4 Incontinence: Supporting your residents with incontinence 3.5 Nutrition: Supporting your residents to eat and drink well 3.6 How to write a care plan for residents at risk/with pressure ulcers

7 8 10 11 12 12

4.0 Other types of skin damage 4.1 Moisture lesions 4.2 Trauma (Skin tears) 4.3 Skin changes at end of life

13 14 15

5.0 Safeguarding your residents 15

6.0 Residents transferring between care settings 17

7.0 References, acknowledgements and further information 17

Appendices Page

A Stages of pressure ulcers (3 pages) 19

B Waterlow risk assessment tool 22

C Guidance on checking mattresses 23

D Example repositioning/turning chart (double-sided) 24

E Resident and family information leaflet 26

F Example wound assessment chart 27

G Pictures of moisture lesions 29

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1.0 The Skin

Why is the skin important?

The skin is the largest organ in the human body and is a protective barrier. It shields the

body against heat, light, injury, and infection. The skin also helps regulate body temperature

and gathers sensory information from the environment e.g. touch, pain, pressure, vibration

and temperature. The skin stores water, fat and vitamin D, and plays a role in the immune

system protecting us from disease. The skin is naturally acidic with a pH of 4.5-6.5 which

inhibits the growth of bacteria and fungi. The skin is made up of three layers which are

outlined in table 1 below.

Table 1: Layers and function of the skin

Layer Thickness Components Function

Epidermis 0.1mm Skin cells Protective shield

Dermis 2 mm Connective tissue, blood vessels, lymph vessels, nerve fibres, sweat glands, hair follicles, sebaceous (oil) glands

Structure and support Temperature regulation Sensation e.g. touch, pain Skin hydration and nourishment

Hypodermis variable Fat cells Connective tissue

Insulation from cold Shock absorption Storage of nutrients and energy

What happens to the skin as we get older?

As the skin ages it becomes thinner and loses elasticity so it becomes more wrinkled and

saggy. The amount of fat under the skin tends to decrease, making the skin more prone to

bruising, more fragile and easily damaged. There is often a reduced blood supply which

means any injuries to the skin may be slow to heal and regulation of body temperature is not

as effective. The loss of natural moisturising factors in the older person’s skin also reduces

skin hydration and causes it to become dry and flaky. Dry skin is itchy and this can lead to

scratching and skin breakdown.

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What causes damage to the skin?

The skin can be damaged by cuts, bruises, scrapes, tearing, constant moisture, friction,

unrelieved pressure and shearing forces (the skin moving in one direction and the body

moving in the opposite direction) as outlined in Table 2 below. In older people, the skin is

more fragile and less resilient and therefore is at high risk of damage from any of the above.

This resource folder contains information regarding pressure ulcers, moisture lesions and

skin tears.

Table 2: Causes of skin damage *Definition from Oxford English dictionary (online) Pressure* Continuous physical force exerted on or against an object by something in

contact with it

Shear* A strain produced by pressure in the structure of a substance, when its layers are shifted laterally (sideways) in relation to each other (the skin and underlying body are pulled in different directions, e.g. when a person slips down the bed)

Friction* The action of one surface or object rubbing against another, e.g. heels rubbing against a sheet

Moisture Water or other liquid, e.g. urine, faeces and sweat in contact with the skin

Trauma Physical injury for example due to cutting, tearing or burning

2.0 Pressure Ulcers

What is a pressure ulcer?

A pressure ulcer occurs when the skin and underlying tissue gets damaged by unrelieved

pressure. Essentially the skin, its blood supply and underlying tissue are squashed between

the hard surface (the cause of pressure) and the underlying bone. The extent of the damage

is dependent on which of the skin layers (see section 1 above) are affected and in serious

cases; the underlying muscle and bone can also be damaged. What you see at the skin’s

surface is often the smallest part of the ulcer, and the tissues under the skin near the bone

suffer the greatest damage. Every pressure ulcer seen on the skin, no matter how small,

should be regarded as serious because of the probable damage below the skin surface.

Damage can result from high pressure for a short period of time or low pressure for a longer

period of time.

In 95% of cases, pressure ulcers are completely preventable with good care and therefore

they are classified as an ‘avoidable harm’. This is why skin damage and pressure ulcers

have to be reported- see section 5.

The areas that are most at risk of developing pressure ulcers are the parts of the body that

are not covered by a high level of body fat (bony prominences) and are in direct contact with

a supporting surface, such as a bed or chair. Common areas are the heels, toes, sacrum,

hips, elbows, shoulders and back of the head as shown in picture 1 below. Pressure damage

can be caused by items other than hard surfaces, for example tight clothes and buttons,

support stockings, wrinkles in the bed sheets, medical devices such as urinary catheters and

oxygen tubing, or body parts laying on each other such as knees/ankles when in bed. Being

observant whilst caring for your residents will help you identify other potential risks to their

skin.

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Picture 1: Common areas at risk of developing pressure ulcers

Pressure ulcers can have a significant impact on the wellbeing of your residents, including long-term pain and distress, embarrassment (some pressure ulcers smell), restricted lifestyle whilst the ulcer is healing and an increased risk of life-threatening infection, such as sepsis. Pressure ulcers are categorised into different stages depending on the extent of damage to the skin and underlying tissues. Appendix A illustrates the different stages of pressure ulcers.

How do I know if my resident is at risk?

There are many factors that increase the risk of developing a pressure ulcer and these are

outlined in table 3 below. Generally anyone living in a care home will be at risk due to a

combination of factors such as their age, reduced independence and levels of mobility and

long term health conditions. Early recognition of individuals at risk of pressure damage is an

essential part of prevention and formal assessment enables the correct interventions to be

started and maintained.

Table 3: Risk factors for developing pressure ulcers

Risk factor Rationale

Age The older you are the more fragile and thin your skin is.

Sex Women are at higher risk due to distribution of body fat compared to men.

Reduced/restricted mobility

The less able a person is to move independently, the less able they are to relieve pressure. Poor moving and handling techniques can increase a person’s risk, particularly moving someone up in the bed/chair as there is an increased risk of both shear and friction forces on the skin.

Condition of the skin including previous pressure ulcers

Skin that is already compromised or damaged is at greater risk of further breakdown. A history of previous pressure ulcers constitutes high risk

Body shape Being underweight means the skin has less fat to provide protection whereas being overweight means the additional body weight adds extra pressure.

Reduced sensory function

Reduced sensitivity to feeling pain and pressure (due to a medical condition or nerve damage) makes it harder to recognise that something is wrong.

Incontinence Exposure to constant moisture damages the skin, urine and faeces are particularly irritating.

Appetite and diet Good nutrition and hydration are important to keep the skin healthy and to promote healing in any damaged areas.

Medicines Some medicines affect the thickness of the skin e.g. steroids and anti-inflammatories or make the skin more prone to bruising e.g. anticoagulants.

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Other health conditions Some medical conditions affect the blood supply to the skin and therefore it receives less oxygen and nutrients to keep it healthy. Examples include diabetes, organ failure, peripheral vascular disease and anaemia. Neurological conditions (affecting the brain and/or spine) such as stroke and multiple sclerosis impact on the skin due to a combination of reduced mobility, changes to sensation, blood circulation and medicines. Being completely immobile for a period of time (usually 2 days or longer) increases the risk. Examples for care home residents include a period of illness requiring bed rest, a visit to A+E where they will be lying or sitting on a trolley, waiting in transport lounge.

Every resident should have their risk of developing pressure ulcers assessed using a

validated tool such as the Waterlow risk assessment scale. This should be completed

within 6 hours of admission to the care home (NICE 2014). The risk should also be

reassessed as frequently as required and when there is a clinical concern or change in

the person’s mental or physical status, for example in the following situations:

• weight loss or change to appetite

• changes to the skin e.g. bruises, cuts

• changes to continence e.g. diarrhoea or increasing episodes of incontinence

• prolonged or recurrent illness or infection

• changes to mobility levels

If your resident has been in hospital (or another care setting), it is good practice to reassess

their risk of pressure ulcers (and other risk assessments) when they return to the care home,

in case they have changed whilst in hospital.

A copy of the Waterlow tool can be found in Appendix B.

Interpreting the Waterlow score -What to do next?

The action required will be slightly different depending on whether your resident has scored

between 10-14 (at risk), 15-19 (high risk) or more than 20 (very high risk). The main

differences will be what type of pressure ulcer prevention strategies will be required. For

every resident, it is important to initiate prevention measures which can be remembered by

the abbreviation SSKIN: Surface, Skin, Keep moving, Incontinence, Nutrition (see

http://nhs.stopthepressure.co.uk). The SSKIN preventative measures relate to the risk

factors that can be addressed and modified and they are discussed further below. Health

conditions that affect the risk of developing pressure ulcers should be reviewed and their

treatment and management optimised in liaison with the GP (e.g. good control of diabetes

and blood glucose levels). A medication review can identify medicines that are affecting the

risk score and consider whether this risk can be reduced.

Registered nurses need to initiate preventative measures (using SSKIN principles outlined

below), including the provision of suitable pressure relieving equipment and minimising

known risk factors. Any wounds or pressure ulcers identified during the risk assessment

require a management plan.

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3.0 Minimising risk using SSKIN prevention guidance

3.1 Surface

This refers to the surface that residents are sitting or lying on, in other words, the chair

cushion and bed mattress. The surface underneath the resident needs to provide the right

amount of support and comfort and no resident at risk of pressure ulcers should be nursed

on anything less than a high-specification foam mattress (NICE 2014). Residents are at

greater risk of pressure damage when seated than they are when lying in a bed due to the

distribution of their body weight. Continue to move residents frequently whatever the type of

support surface is used and make sure bedclothes and clothing are smooth under the

resident when repositioning. Don’t use too many Inco sheets or plastic-backed Inco sheets

as this may make the skin sweat more and add risk of moisture on the skin (see section 4.1).

It is important to use the correct moving and handling techniques as tissue damage may also

occur when a resident slumps in a chair or slips down the bed during repositioning.

Support surfaces may also be described as pressure relieving equipment that work by either

spreading out the pressure (redistribution) or removing pressure regularly from different

parts of the body (alternating). These are expensive sophisticated products which, in the

case of residents at high and very high risk, can make all the difference to their susceptibility

to pressure ulcer damage.

It is important that you know how to check and document that the support surface being

used is in good working order so that it provides the support your resident requires.

How to check a foam mattress

The amount of support a mattress/cushion will provide is dependent on it being fit for

purpose. After a period of use, mattresses/cushions can ‘bottom out’. This can be tested for

by spreading the hands and pushing down on the middle third of the mattress. It should not

be possible to feel the base of the bed. Though a very simple test, it is one that is easily

carried out, and gives you a very good idea of the state of the mattress. Mattresses and

mattress covers should be examined for damage or staining, which will create a risk of cross

infection. Further information for care home managers regarding checking mattresses can

be found in Appendix C.

How to check a pressure-relieving mattress

There are several things that need checking to ensure the mattress will provide the support

that is required. These are outlined in the table below and should be explained in the

manufacturer’s instruction booklet.

Table 4: Things to consider when checking a mattress

Power supply Check it is plugged in and switched on

Weight-setting Is it set correctly for the weight of your resident?

Is there a ‘static’ button (not all mattresses have this)

Is the static button switched to ‘Off’?

Settings/buttons What are the other settings- should they be on/off?

Alarms What do the different alarms mean? What do you need to do to correct the problem?

Cover Is it damaged or stained?

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To select the right mattress, the following need to be considered: the level of risk, weight and

size of the resident, ease of use, moving and handling requirements and any safety issues.

Consult the manufacturer’s instructions to ensure you know how to check the settings,

alarms and that it is working. The mattress settings should be clearly documented on a

pressure ulcer prevention care plan (see section 3.6).

To check that the air mattress is working effectively:

With the resident on the mattress, place a hand underneath the residents heaviest

part (i.e. their pelvis/buttocks)

Press to see if you can feel air supporting the resident. You should not be able to

feel the hard bed-base

If you can feel the hard bed-base, your resident will also feel the bed-base and the

mattress is not providing adequate support.

Pressure relieving equipment should be checked every time the resident is assisted to

change their position and this can be easily documented on a repositioning/turning chart,

see Appendix D. If the equipment is not working as expected, urgent action is required to

rectify the problem to ensure your resident still receives pressure-relief.

3.2 Skin

How to inspect the skin

Routine skin inspection plays a role in decreasing the incidence of pressure ulcers. All

residents should have their skin assessed on admission as part of a holistic assessment and

then checked at least every day. Inspect all areas of the skin regularly, with particular

attention paid to bony prominences (see picture 1) and areas of skin that come into contact

with devices such as catheters, compression stockings etc. A compact mirror is helpful to

visualise difficult to see areas such as the heels when the resident is in a chair.

Encourage and educate residents who are willing and able to inspect their own skin and

ensure relatives know how they can help. A resident and carer information leaflet can be

found in Appendix E.

When inspecting the skin, look for any of the following (early signs of pressure damage):

Reddened areas of skin on light skinned people

Blue/purple patches on dark skinned people

Blisters

Hot or cool areas

Swelling

Signs of irritation, or scratches

Patches of hard skin

Where an area of redness or skin discolouration is noted, it is important to check the integrity

of the skin using the finger test below:

Apply light finger pressure to the area for approximately 3 seconds and then release

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If the area you pressed is white and then returns to its original colour, there is

probably an adequate blood supply

If the area remains red it indicates pressure damage

For individuals with dark skin pigmentation, it may be more difficult to identify changes in

skin colour. Alternative signs such as localised heat (inflammation) or coolness may indicate

pressure damage. The presence of skin blisters over bony prominences is another marker of

early pressure damage. Do not ignore any signs of early skin damage or assume an area of

discolouration is simply superficial damage; deep tissue damage may present as an area of

purple discolouration.

Where skin is intact;

Keep the skin healthy and well hydrated

Continue to inspect the skin daily

Continue to use SSKIN prevention measures

For areas at risk of breakdown, consider using appropriate skin protection products

to maintain skin integrity

Initiate a pressure ulcer prevention care plan

Where an area of redness, discolouration or breakdown is noted:

If non-blanching erythema is noted, the skin should be reassessed every 2 hours until

resolved (NICE 2014).

Document what you see on a wound chart, including the location, size, depth, stage and the

state of the wound bed. An example wound chart can be found in Appendix F. If your

resident consents, take a photograph for your records, ideally using a camera with integral

grid to enable accurate measurement. Initiate a treatment plan, utilising the latest guidance

in the Sutton Community Health Services Wound care Formulary to identify the correct

dressing to use. Document areas of pressure damage in the health records and implement a

pressure ulcer management care plan (see section 3.6). The time to heal and frequency of

re-dressing the wound will be variable depending on the extent of the wound and the

dressings used. If the wound does not appear to be healing, refer to the Tissue Viability

Nurse specialist (TVN) for further advice and assessment. It is good practice to seek advice

from the TVN for all stage 3 and 4 or multiple stage 2 pressure ulcers. Increase the

frequency of skin inspection, initiate a repositioning/turning chart and initiate other

preventative strategies immediately to reduce pressure to affected areas. Complete a pain

assessment and liaise with the GP to ensure adequate pain relief. Any damage to resident’s

skin, including pressure ulcers are notifiable to the CQC and local safeguarding team- see

section 5.

How to keep the skin healthy

Dry, fragile skin should be rehydrated using a simple, unperfumed moisturiser. Application of

the moisturiser should follow the direction of the body hair and be gently smoothed onto the

skin. Skin cleansers can be used to clean the skin without rinsing (traditional soaps should

be avoided as they can irritate the skin) and be dried gently. Eating well and drinking enough

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water can also keep skin healthy and is vital for wound healing. Fragile skin is at high risk of

tearing and therefore if dressings or tapes are needed, these should be non-adherent (non-

sticky) dressings. Residents should be encouraged to keep their nails clean and short to

reduce the risk of accidental skin tears and infection.

If skin becomes too wet, it can become soggy and more easily damaged. It is important to

protect the skin from contact with urine and faeces and the harmful irritants in them. Where

skin changes are due to excessive moisture, barrier films or creams may also be used to

create a protective layer (see section 4.1).

Particular care should be taken to ensure that areas of skin folds e.g. buttocks, under

breasts and in tummy folds are thoroughly dried. For residents who have contractures (a

disorder in which there is abnormal shortening of a muscle so it becomes permanently

tightened (contracted), there is a higher risk of skin breakdown due to it being more difficult

to keep the area clean and dry. Seek advice for residents who have contractures of the

hands due to the risk of their fingernails digging into the palm of the hand and causing

pressure ulcers.

3.3 Keep moving

To prevent skin damage and pressure ulcers it is important that your resident keeps moving

as much as possible and residents who are immobile are at highest risk of developing

pressure ulcers. Regular movement or repositioning will redistribute pressure and help

prevent pressure damage. Residents who are being cared for on a support surface still need

to be repositioned.

Residents who are able to get out of bed or their chair should be encouraged to do so

whenever possible. Teach residents to change position (offload) every 15 minutes. These

movements need only be small but may give a significant difference in pressure. Changing

position can be incorporated into everyday activities, e.g. standing up to get a drink,

walking/transferring to the toilet.

For residents who need help, reposition at least every 1-2 hours when sitting in a chair or in

bed e.g. on their left side, then on their back, then on their right side. Residents who have

actual damage to their sacral area should only sit out for 45mins-1 hour at a time (depending

on severity). When deciding how frequently repositioning is required, consider the wishes of

the resident and what they are able to tolerate. Changes to position should be recorded on a

repositioning/turning chart, see example in Appendix D. It is important that manual handling

aids are used when moving residents e.g. sliding sheets, to avoid dragging the resident

along the mattress. To help residents maintain their position when in bed, use a

wedge/pillow to maintain a 30-degree side-lying position. Raise the head of the bed to less

than 30 degrees to prevent them slipping down the bed. A 30-degree tilt can also be

achieved in a reclining chair using a wedge/pillow. This will reduce the risk of placing

additional pressure on the hip area.

Ensure the resident knows why they are being repositioned and encourage those who can

do it for themselves. Ensure relatives know how they can help to reduce the risk. Sometimes

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residents refuse to move or have their position changed for them and further advice on how

to manage this situation is outlined in section 5.

3.4 Incontinence

Both urine and faeces are highly irritating to the skin, making it more susceptible to pressure

damage and therefore it is important to maintain continence and actively manage

incontinence. Incontinence is not a normal or inevitable part of ageing and has many

different causes. Always check whether your resident has a urinary tract infection (UTI) as

this can be a cause of incontinence in the elderly or make incontinence worse. Where

continence problems are identified, the resident should have a full continence assessment to

identify the cause and develop a management plan. Some residents will benefit from a

referral to the continence service to ensure their continence is being optimally managed.

There are a few easy ways to promote continence and reduce the risk of moisture sitting on

the skin:

Take the ‘Toilet First’ approach, ensuring residents can access toilet facilities, wear

clothing that is easy to remove and are regularly offered support to visit the toilet

(every two to four hours). For residents who are regularly incontinent, it may be

helpful to develop a timetable that offers a reminder for going to the toilet.

Gently clean and dry the skin when continence pads are changed or incontinence

occurs. Wash gently, do not rub.

Avoid using traditional soaps as they can irritate the skin. Skin cleansing products

can be used to clean the skin without rinsing or use a low pH soap which is less

irritating.

Apply a barrier cream or spray, following manufacturers’ instructions on how to apply.

Prevent the resident becoming too hot and sweaty.

Ensure your resident is not constipated as this may have an impact on continence;

monitor their bowel activity using the Bristol stool chart.

Ensure residents drink enough fluids to prevent them becoming dehydrated.

Consider asking the care home pharmacist for a medication review as some

medicines can affect continence.

If using pads, use 1 pad only, folding length-ways to form a channel. Continence

pads should be changed as often as is necessary.

Do not use thick creams, ointments or talcum powder as these can reduce the

absorbency of the continence pad.

If the resident has a catheter, ensure the bag is emptied regularly to prevent it

becoming too heavy. Catheter tubing should be secured safely and any problems

with the catheter addressed quickly.

Continence aids:

Using continence aids can help to keep the resident comfortable and protect skin when used

appropriately. Incontinence pads and pull-up pants can be worn day and night, or during the

night only, to draw fluids away from the skin. It is important to find the right type and

absorbency for the individual. They should be comfortable without chafing the skin or

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leaking. They should be changed as often as necessary. Male residents may benefit from

using a male continence sheath and these may be particularly helpful when worn at night.

3.5 Nutrition

Adequate nutrition and hydration is important for preventing as well as healing pressure

ulcers. A nutritional assessment, for example using MUST, will identify residents who are not

receiving enough nutrition.

Encourage residents to eat a healthy balanced diet and have regular drinks, ensuring

residents have a choice and variety available. Encouraging participation in the activities

surrounding preparing and serving meals will also keep your residents moving. Assist

residents who find eating meals difficult and ensure those at risk of malnutrition are referred

to a dietician. If a resident develops a pressure ulcer, it is good practice to refer them to the

dietician to ensure their diet is sufficient to enable the ulcer to heal.

More information about nutritional assessment and helping residents to eat and drink

enough can be found in ‘Nutrition and Hydration- Guidance for nursing and residential care

homes’.

3.6 How to write a care plan for residents at risk of/ with pressure ulcers

Residents who are at risk of developing pressure ulcers need to have a care plan that

concisely outlines what specific support is required to enable that person to prevent pressure

damage and reduce their risk score. Those who have skin damage or a pressure ulcer will

also need a care plan that outlines how the pressure ulcer is being managed and how to

promote healing and prevent further damage. Care plans should be written in discussion

with the resident and their family and should be specific, measurable, achievable, realistic

and time-framed (SMART).

The care plan for prevention should outline the following:

1. How often you will reassess their risk of developing pressure ulcers

2. What support surface the resident should be using in the bed/chair, how often this

will be checked that it is working properly and how you will know if it is not working or

intact. If they are using a pressure-relieving mattress, the correct settings should be

documented

3. How often you will inspect their skin and what you are looking for that indicates

potential skin damage. If they have specific items that pose a pressure risk, such as

support stockings or a catheter, how will these areas be checked

4. How will you encourage the resident to change position (or support those who are

unable to move themselves), how often this needs to happen and where will this be

documented e.g. turning chart. For those who are unable, include the moving and

handling equipment required to change their position and refer to their moving and

handling care plan

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5. If there are continence issues, how are these being managed to reduce the impact of

urine/faeces on the skin and refer to their continence care plan. If barrier

creams/sprays are being used, where and how often should these be applied

6. If nutrition and hydration are contributing to the risk level, what steps are you taking

to address this, e.g. fluid chart or additional protein snacks. Refer to their

nutrition/hydration care plan

7. If they are using any other pressure relieving equipment e.g. heel protectors, when

should it be used and for how long

8. How you will monitor whether the care plan interventions are successful

9. What to do if interventions are not having the impact expected i.e. when and how to

refer to the TVN for further advice

The care plan for those with a pressure ulcer should outline the following:

Elements 1-9 above

What treatment/dressing is being used (or refer to the wound chart if this includes

this information) and what to do if the dressing comes off

How often the pressure ulcer requires reassessment

4.0 Other types of skin damage

4.1 Moisture lesions

What is a moisture lesion?

A moisture lesion is defined as erosion of the skin due to excessive moisture. The moisture

is usually caused by urine, faeces or perspiration. The skin is naturally acidic and both urine

and faeces are alkaline, thus changing the acidity of the skin and causing it to breakdown.

Exposure to excessive moisture causes the skin to become damp, soggy and clammy and

increases the risk of infection and damage due to other reasons e.g. pressure, shearing and

friction. The skin affected by a moisture lesion can be described as excoriated (red and dry)

or macerated (red and white, soggy and shiny). Moisture lesions are most likely to develop in

skin folds e.g. between the buttocks and groin area (particularly with urine and faeces) or

underneath the breasts or folds of tummy (particularly with perspiration). Moisture lesions

can be extremely painful.

Moisture lesions are sometimes confused with pressure ulcers however there must be

moisture present before you develop a moisture lesion. Moisture lesions also look different

to pressure ulcers; they are superficial, with irregular edges, look red or pink and are

‘blotchy’. Appendix G shows what a moisture lesion might look like and Table 5 below

outlines the difference between a moisture lesion and a pressure ulcer. Be aware that

residents can have both a moisture lesion and a pressure ulcer.

Table 5: Differentiating between a moisture lesion and a pressure ulcer

Characteristic Moisture lesion Pressure ulcer

Cause Moisture must be present e.g. shiny wet skin caused by urinary incontinence or diarrhoea

Pressure and/or shear must be present

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Location Skin folds, particularly buttocks, inner thigh and groin area Less likely over bony prominences

Most common over bony prominences (unless the pressure has been caused by a piece of equipment e.g. urinary catheter)

Shape Irregular shape May be linear or mirror image Diffuse, in several superficial spots

Usually circular Regular shape

Depth Superficial skin loss Superficial or deep, dependent on stage of ulcer

Colour Non-uniform redness Blanchable or non-blanchable erythema Pink/white surrounding skin

Uniform redness

Edges Diffuse or irregular edges Distinct edges, may be raised

Necrosis No necrosis A black necrotic scab may be present, dependent on stage of ulcer

How to prevent and manage a moisture lesion

The best way to prevent and manage a moisture lesion is to ensure that all skin areas are

kept clean and dry. For residents with continence problems, ensure they are offered regular

toileting and that the skin is gently cleaned and dried when continence pads are changed or

accidents happen. Wash gently, do not rub and use a cleansing wash rather than soap and

water (unless low pH soap). Residents whose skin is a risk from exposure to moisture (e.g.

those with episodes of urinary or faecal incontinence) may benefit from using a barrier cream

or spray (e.g. Conotrane) on certain areas such as the buttocks. These provide a waterproof

protective layer to prevent moisture coming into contact with the skin. Ensure you read the

instructions for any barrier cream or spray as different brands require a different frequency of

application to the skin. Some residents will benefit from a referral to the continence service

to ensure their continence is being optimally managed. For severe moisture lesions, a

referral to the TVN may be required.

4.2 Trauma- skin tears

What is a skin tear?

The skin of older people is thin and fragile and is therefore at high risk of cuts and tears. The

skin is easily torn when in contact with sharp edges and objects such as jewellery,

wheelchair levers and footplates and watches. The risk factors for developing skin tears are:

Previous history Shearing, friction and pressure

Older age Bruising

Impaired mobility Dry or fragile skin

Impaired vision Medications

Cognitive impairment, e.g. dementia

Health conditions affecting the kidneys, heart or lungs

Impaired sensation Poor nutrition and hydration

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How to prevent a skin tear

Skin tears are painful and if not managed properly could develop into a nasty wound with a

high risk of infection. There are many things you can do to prevent your residents tearing

their skin. These include:

Keep fingernails short (residents and staff)

Beware of jewellery (residents and staff)

Use the correct moving and handling techniques

Beware of wheelchairs, particularly foot plates and levers

Use padding to protect vulnerable areas e.g. bed rails and wheelchair arms

Ensure good lighting

Keep residents skin moisturised

Ensure good nutrition and hydration

Encourage long-sleeved clothing

Be vigilant

How to manage a skin tear

Rinse with sterile normal saline (0.9%NaCl)

Pat dry (clean gauze), applying gentle pressure if bleeding

Ensure the flap of skin is returned to its normal position

Cover with a soft silicone-coated atraumatic net dressing (e.g. Atrauman; Silfix etc.)

Indicate the direction of the skin fold

Leave dressing intact, keep dry

Review after 24-48 hours, depending on size

Monitor for indicators of non-healing e.g. signs of infection, hot, redness, behaviour

change

4.3 Skin changes at end of life

As a person reaches end of life, all the organs of the body start to shut down and slowly stop

functioning. This includes the skin. Changes at the end of life may affect the skin and soft

tissues and changes in skin colour, texture or integrity can be seen. These changes may

also cause pain and may be unavoidable despite appropriate interventions.

Signs and symptoms associated with Skin Changes At Life’s End (SCALE) may include:

Muscle weakness and loss of mobility/unable to move independently

Loss of appetite, weight loss, not eating or drinking.

Reduced supply of blood and oxygen to the skin

The management of skin changes at end of life are exactly the same and the prevention of

skin damage and management of pressure ulcers should follow the SSKIN principles

discussed above. The goals of care are prevention of skin breakdown, promoting healing of

existing wounds, providing palliation and comfort (managing pain, minimising odour and risk

of infection) and responding to residents’ preferences and wishes.

The supportive care home team can provide further advice and guidance around

individualised care planning to support residents at end of life.

16

5.0 Safeguarding your residents

Reporting incidents and safeguarding

The majority of pressure ulcers can be prevented and therefore when they happen, they

need to be reported, either as an incident or as a safeguarding. Care Quality Commission

(CQC) Regulation 18 outlines that all incidents that affect the health, safety and welfare of

people who use services are reportable to the CQC and should also be reported to the

commissioner for that bed (e.g. local authority or continuing healthcare).

Regulation 18 states:

Any injury to a service user which, in the reasonable opinion of a health care

professional, has resulted in

o changes to the structure of a service user's body,

o the service user experiencing prolonged pain or prolonged psychological

harm

Injuries include those that lead to damage to

o any major organ of the body (including the brain and skin)

o bones

o muscles, tendons, joints or vessels

o the development after admission of a pressure ulcer of stage 3 or above (or

multiple stage 2) that develops after the person has started to use the service

It is good practice to report all incidents of resident harm, including all stages of pressure

ulcers to the local authority and CQC. The Safeguarding Vulnerable Adults team at the local

authority will determine whether incidents relating to the development of skin damage and

pressure ulcers require a safeguarding investigation. Stage 3 or 4 pressure ulcers,

‘unstageable’ pressure ulcers and multiple stage 2 ulcers must be reported as a

safeguarding alert.

Care providers also have a Duty of Candour (honesty) to inform the resident and their family

members or appropriate others who are involved regarding any pressure damage acquired

at the home.

Managing residents’ choice and capacity

It is not unusual for residents to refuse to change position or allow care staff to help them

turn in bed. For residents with the capacity to make decisions, it is important that you help

them to understand what pressure ulcers are, why they are at risk and what they can do to

prevent skin damage occurring. You may find the resident information leaflet in Appendix E

helpful. If the person has capacity and refuses care, their reasons for refusal should be

addressed and clearly documented in their notes. They should continue to be offered the

care daily (or again later the same day as appropriate) as people do change their mind.

For residents who lack the capacity to make decisions regarding their pressure area care, a

best interests meeting must be arranged by the care home to discuss this element of their

care requirements. The best interest meeting should involve the family members or

advocate, the GP and any other people involved in the care of that resident (e.g. allocated

social worker, continuing healthcare if they are funding the placement, TVN). The outcome

17

must be clearly documented in their care notes. If additional restrictions are subsequently put

in place in order to deliver care in the persons best interests, and they are subject to a DoLS

(deprivation of liberty safeguard) the relevant Best Interest Assessor should be informed.

Clear documentation of discussions about pressure area care with residents and their family

members or appropriate others who are involved will reduce the chances of the home being

accused of poor care in the event of a resident developing pressure ulcers.

6.0 Residents transferring between care settings

For residents who are at risk or have identified damage to their skin for example a pressure

ulcer, moisture lesion or bruising, it is important that this information is communicated if the

resident has to go to another care setting e.g. hospital, outpatient appointment, day centre,

hospice or other. Staff in these settings will be responsible for ensuring your residents skin

integrity is maintained whilst they are there, however they will not know the specific care

requirements for your resident. In these situations, it is important to send with them the

Waterlow score, a body map and/or wound chart and copies of their skin integrity/pressure

ulcer care plans. This will ensure your resident is supported to keep their skin healthy (or

have their pressure ulcers/ wounds appropriately managed) whilst they are out of your care.

Good documentation and communication with other care settings also helps to prevent the

potential for a safeguarding alert for residents attending hospital with skin damage.

7.0 References

Alzheimer’s Society. 2016. Continence and using the toilet. Available at:

https://www.alzheimers.org.uk/download/downloads/id/1792/factsheet_continence_and_usin

g_the_toilet.pdf 2016

Beldon, P. 2010. Skin changes at life’s end (SCALE): a consensus document. Wounds UK

6(1). http://www.wounds-uk.com/pdf/content_9356.pdf

Care Quality Commission. 2009. Regulation 18: Notification of other incidents. Available at:

http://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-18-notification-

other-incidents#full-regulation

European Pressure Ulcer Advisory Panel. 2009. SCALE: Skin changes at life’s end, final

consensus statement. Available at: http://www.epuap.org/wp-

content/uploads/2012/07/SCALE-Final-Version-2009.pdf

Guy, H. 2012. The difference between moisture lesions and pressure ulcers. Wounds

Essentials, Volume 1. Available at: http://www.wounds-uk.com/pdf/content_10448.pdf

NHS Midlands and East. (Date unknown). How to: keep residents’ skin healthy. Available at:

http://www.lovegreatskin.co.uk/downloads/howtogreatskinHEALTHYfinal.pdf

NHS Midlands and East. (Date unknown). How to: Use support surfaces appropriately.

Available at: http://www.lovegreatskin.co.uk/downloads/howtogreatskinsupportfinal.pdf

18

NHS Midlands and East. (Date unknown). How to: maintain high quality nutritional care.

Available at: http://www.lovegreatskin.co.uk/downloads/howtogreatskinnutritionfinal.pdf

NHS Midlands and East. (Date unknown). How to: manage incontinence/moisture. Available

at: http://www.lovegreatskin.co.uk/downloads/howtogreatskinincontinencefinal.pdf

NHS Midlands and East. (Date unknown). How to: Keep patients moving. Available at:

http://www.lovegreatskin.co.uk/downloads/howtogreatskinmovingfinal.pdf

Nursing and Midwifery Council. 2015. The code for nurses and midwives. Available at:

https://www.nmc.org.uk/standards/code/

Waterlow, J. 2007. Pressure ulcer prevention aids. Available at: http://www.judy-

waterlow.co.uk/pressure_ulcer_preventative_aids.htm

Wounds UK. 2012. Moisture Lesions Supplement. Wounds UK, London. Available at:

http://www.nhs.stopthepressure.co.uk/docs/WUK%20moisture%20lesion%20supplement%2

02012.pdf

Sources of further information (all of these include resources specifically for carers and

care homes)

www.reacttoredskin.co.uk

www.nhs.stopthepressure.co.uk

www.lovegreatskin.co.uk

The following factsheets for carers may be useful:

1. Support me, http://nhs.stopthepressure.co.uk/love-great-

skin/LOVE%20GREAT%20SKIN%20support%20me%20factguide.pdf

2. Keep me moving, http://nhs.stopthepressure.co.uk/love-great-

skin/LOVE%20GREAT%20SKIN%20keep%20moving%20factguide.pdf

3. Feed me well, http://nhs.stopthepressure.co.uk/love-great-

skin/LOVE%20GREAT%20SKIN%20nutrition%20factguide.pdf?v=L1WKZwh2Hpg

4. How to manage Incontinence, http://www.nhs.stopthepressure.co.uk/How-

ToGuides/howtogreatskinincontinencefinal.pdf

Acknowledgements:

This guidance document was supported by information provided by The Royal Marsden

Hospital Community Services.

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Appendix A: Different stages of pressure ulcers

Stage 1 Skin is not broken but is red or discoloured or may show changes in hardness or temperature compared to surrounding areas. When you press on it, it stays red and does not lighten or turn white (blanch). The redness or change in colour does not fade within 30 minutes after pressure is removed. On dark skin tones, the redness may not be easily seen however skin may instead look purple or blue-ish.

Healing time: approximately 3-7 days

Stage 2 The topmost layer of skin (epidermis) is broken, creating a shallow open ulcer. The second layer of skin (dermis) may also be broken. Drainage (pus) or fluid leakage may or may not be present.

Healing time: approximately 3 days- 3 weeks

20

Stage 3 The wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue. Bone, tendon and muscle are not visible. Look for signs of infection (redness around the edge of the ulcer, pus, odour, fever, or greenish drainage from the ulcer) and possible necrosis (black, dead tissue).

Healing time: approximately 4 weeks-6 months

Stage 4 The wound extends into the muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present. There is a high possibility of infection.

Healing time: approximately 3 months- 2 years

21

Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (top picture) or eschar (bottom picture). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Slough = dead tissue separated from living tissue, usually yellow, tan, grey, green or brown colour Eschar = a scab, usually tan, brown or black colour in the wound bed

Suspected Deep Tissue Injury Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This type of pressure ulcer cannot easily be categorised as the extent of damage to underlying tissues cannot be determined

Adapted from The National Pressure Ulcer Advisory Panel. http://www.npuap.org/online-store/home.php?cat=249

22

Appendix B: Waterlow risk assessment

WATERLOW RISK ASSESSMENT Residents Name:

Date (Day/Month/Year) Time

Gender Male 1

Female 2

Age

14 - 49 1

50 - 64 2

65 - 74 3

75 - 80 4

81 + 5

Build

Average BMI 20 – 24.9 0

Above average BMI 25 – 29.9 1

Obese BMI > 30 2

Below average BMI < 20 3

VISUAL ASSESSMENT OF AT RISK SKIN AREA (select one or more options)

Healthy 0

Thin and fragile 1

Dry 1

Oedematous 1

Clammy (Temp ↑ ) 1

Previous pressure ulcer or scarring 2

Discoloured Stage 1 2

Broken Stage 2 - 4 3

MOBILITY (Select one option

ONLY)

Fully 0

Restless/fidgety 1

Apathetic 2

Restricted/Bed bound 3

Inert (due to ↓consciousness) 4

Chair bound/Wheelchair 5

CONTINENCE (select one option

ONLY)

Continent/catheterised 0

Occasional incontinence 1

Incontinent of Urine 2

Incontinent of Faeces 2

Doubly incontinent 3

Tissue Malnutrition (select one or more options)

Terminal Cachexia 8

Multi Organ Failure 8

Single Organ Failure (Respiratory/Renal/Cardiac)

5

Peripheral Vascular Disease 5

Anaemia HB < 8 2

Smoking 1

Appetite (select one

option)

Average 0

Poor 1

N.G Tube/ Fluids only

2

NBM/anorexic 3

Neurological Deficit

(score depends on severity)

Diabetes, CVA, MS, Motor/Sensory Paraplegia, epidural

4-6

Major Surgery Trauma

(up to 48 hours post-surgery)

Above waist 2

Orthopaedic, below waist, spinal > 2 hours on theatre table

5

6 hours on theatre table 8

MEDICATION Cytotoxics, high dose/long term Steroids, Anti-inflammatory

4

TOTAL SCORE

INITIALS

Risk Score: 10+ AT RISK 15+ HIGH RISK 20+ VERY HIGH RISK

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Appendix C: Mattress checking- guidance for care home managers

The support surface underneath the resident is an important factor in preventing skin

damage due to pressure. ‘Support surface’ applies to chair cushions and bed mattresses

and includes ‘regular’ cushions/mattresses as well as those specifically designed to be

‘pressure-relieving’.

There are many different products available, each of which will have specific characteristics

and instructions for appropriate use and care. There are a couple of principles that apply,

regardless of the product selected for purchase.

All covers should be made of 2-way stretch material, to reduce the risk of adding to the

shearing forces on a resident’s skin.

Every care environment needs a mattress monitoring plan which identifies the time intervals

for testing and replacement. All mattresses should be dated at the time of first use. The ends

of the bed should be identified from 1- 4 to give an easy reference to systematic turning, end

to end, and top to bottom. Some companies supply pressure mattresses already marked

with this information.

Further information on selecting a suitable support surface can be found at the Disabled

Living Foundation http://www.dlf.org.uk/factsheets/pressure-relief or Wounds-UK

http://www.wounds-uk.com/pdf/content_10638.pdf

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Appendix D: Example Repositioning / Turning Chart

Repositioning chart Residents name: Week beginning:

Sunday Monday Tuesday

Time Side Pressure areas checked?

Mattress working?

Sig. Side Pressure areas checked?

Mattress working?

Sig. Side Pressure areas checked?

Mattress working?

Sig.

0100

0200

0300

0400

0500

0600

0700

0800

0900

1000

1100

1200

1300

1400

1500

1600

1700

1800

1900

2000

2100

2200

2300

2400

Key: L= left side, R= right side, B= on back

Pressure areas to check: head, shoulders, elbows, buttocks/sacrum, hips, knees, ankles, heels and other (please specify)

Equipment checks: Is it plugged in and switched on? Are all settings correct? Is it working?

25

Repositioning chart Residents name: Week beginning:

Wednesday Thursday Friday Saturday Time Side Pressure

areas checked?

Equipment working?

Sig. Side Pressure areas checked?

Equipment working?

Sig. Side Pressure areas checked?

Equipment working?

Sig. Side Pressure areas checked?

Equipment working?

Sig.

0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400

Key: L= left side, R= right side, B= on back

Pressure areas to check: head, shoulders, elbows, buttocks/sacrum, hips, knees, ankles, heels and other (please specify)

Equipment checks: Is it plugged in and switched on? Are all settings correct? Is it working?

26

Appendix E: Information for residents and family

27

Appendix F: Example wound assessment chart

Residents Name: Date of first assessment: Background information

Duration of wound (PleaseTick) Acute (<6 weeks) Chronic (>6 weeks)

Type of wound (Please Tick) Pressure ulcer Burn/scald Skin tear/ laceration Moisture lesion Leg ulcer

Diabetic foot ulcer Sinus/fistula Traumatic wound Surgical wound Other

If pressure ulcer, what category? 1 2 3 4

Factors affecting wound healing:

Comments Actions

Diabetes

Nutritional Status

Medications

Other

Allergies including dressings and tapes:

Location of wound:

Initial assessment

Review Review Review

Date:

Wound size: Max. length (cm) Max. width (cm) Max. depth (cm) Undermining/tracking?

Wound bed: Necrotic (black) Slough (yellow/brown) Granulating (red) Epithelialising (pink) Overgranulating Bone/ligament/tendon visible?

Infected/critically colonised?

Surrounding skin: Healthy/intact Fragile

28

Dry/cracked Scaly Erythema Macerated Oedematous Excoriated Skin nodules Skin stripping Other (state)

Exudate level: None Low Moderate High Increasing? Decreasing?

Odour: None Slight Moderate Strong

Bleeding: None Slight Moderate Heavy At dressing change

Infection suspected? Swab taken? (Y/N)

Signature/designation of assessor

Other actions required (insert date completed) Photograph taken Pressure relieving equipment in place

MUST reviewed Waterlow reviewed Pain assessment completed

Wound management care plan completed

Family and care staff informed

Reported to CQC Reported to safeguarding

Duty of candour required?

Referrals required? E.g. TVN, podiatry, dietician, other

Reason for referral

Signature/designation

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Appendix G: Pictures of moisture lesions