The largest organ in the body…

Skin accounts for 15% of a person’s overall body weight.

The skin’s three layers, Epidermis (Outer), Dermis (Middle), and subcutaneous tissue are responsible for:

Protecting the body, from mechanical damage, from UV light, bacteria and other damaging toxins

Acting as a pain receptor, helping the body to recognise damage such as pressure, heat or cold

Regulating body temperature, by being able to shiver or sweat to help warm or cool the body

Providing a barrier against infection

Synthesising sunlight into Vitamin D for healthy bones

Pressure Damage in Care Homes

Maintaining healthy skin of elderly people in care homes is paramount in providing good care.

If skin breaks down, it causes pain; discomfort and can lead to infection, sepsis and even be fatal.

As the skin ages, it becomes thinner and loses collagen and elastin. This means that skin becomes more fragile and susceptible to damage. When damage occurs, it can take much longer to heal.

Pressure damage is a burden to healthcare environments and residents, both financially and in terms of reduction in quality of life.

The Care Quality Commission monitors standards in care homes. Preventable pressure damage should be reported for investigation, to adult safeguarding.

Safeguarding of vulnerable adults is defined as helping people with care and support needs to live full lives, free from abuse and neglect (Social Care Institute for Excellence [SCIE], 2015).

Development of avoidable pressure damage can be seen as an act of neglect or harm, and therefore a safeguarding issue.

Pressure damage of Grade 3 or more must be reported by the care home to CQC under their statutory notifications guidelines.

Risk Assessment

Risk assessment is an essential part of preventing pressure damage, by identifying and treating those at risk.

Upon admission to a care home people should be risk assessed within six hours and an appropriate treatment plan put into place, for example: use of pressure reducing equipment, a repositioning schedule and topical barrier creams.

All individuals ‘at risk’, or with existing pressure ulcers should be assessed within six hours of start of admission to the episode of care and reviewed on a regular basis throughout their stay (NICE, 2005).

Tools such as the Waterlow score and Braden scale are popular in care homes for the assessment of risk for development of pressure sores and pressure ulcers.

Assessing Wounds

Wound assessment is a process to determine the causative and contributory factors leading to the development of a wound.
This process should also identify the reasons that could delay the wound healing in an individual.

Wound assessment involves assessing the wound and its surrounding areas, selecting an effective treatment plan and continuous evaluation throughout the duration of the wound.

Who should assess wounds?

Only people with the appropriate skills and training should be assessing wounds. In the care home, staff may request the advice of district nurses or Tissue Viability Nurses.

With wounds affecting the feet, this could also involve the podiatry team.

Carers should only act within the boundaries of their capabilities and always refer onwards when unsure to avoid further damage to the resident.

Residents and their loved ones should also be involved in the wound assessment process, especially if there are likely to be issues around non-concordance.

A good wound assessment should include:

  • Resident medical history
  • History and duration of the wound
  • Cause of the wound
  • Grade of the wound
  • Size and depth of the wound
  • Condition of the skin surrounding the wound
  • Any signs or symptoms of infection
  • Exudate levels

Categorising Pressure Ulcers

The International EPUAP/NPUAP Pressure Ulcer Classification System (2009) is commonly used to categorise ulcers:

There are several classifications of pressure ulcers, as follows:

  • Stage I

Intact skin with non-blanchable erythema of a localised area usually over a bony prominence. Discolouration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. The area may be painful, firm, soft, warmer or cooler than adjacent tissue.

  • Stage II

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or bruising. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

  • Stage III

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contract, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

  •  Stage IV

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

  • Unstageable – Depth Unknown

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed.

  • Suspected Deep Tissue Injury – Depth Unknown

Purple or marron localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

  • Moisture Lesions

Redness or partial thickness skin loss involving the epidermis, dermis or both caused by excessive moisture to the skin from urine, faeces or sweat. These lesions are not usually associated with a bony prominence. They can however be seen alongside a pressure ulcer of any grade.

Residents with moisture lesions will benefit from a continence assessment to ensure that the correct products are used to encourage the skin to heal.

  • Skin Tears

Skin tears are common in elderly people with fragile skin. They are usually caused by trauma, although this can usually be something minor like a small bump if the skin is very delicate.

Skin tears can still be very painful for residents and it is important that they are treated correctly and promptly.

If skin flaps can be realigned, then they should be after cleansing. The skin tear needs to be covered with a suitable non-adhesive dressing and monitored for signs of infection. Pain should be monitored and managed as necessary.

Good Skin Care Principles

  • Thorough assessment and treatment plans for people with skin that is at risk
  • Measure and photograph wounds as part of the management plan so that deterioration can be identified quickly
  • Good skin hygiene, using a soap substitute. Soap is very drying and can further exacerbate problems experience in older people with frail skin
  • Topical emollients can be used to help skin hold its essential moisture
  • Move frequently is the best advice we can offer residents in order to maintain healthy skin and prevent pressure damage
  • Manage incontinence as it plays a large part in the development of skin problems. Consider referral to the continence team so that an assessment can take place
  • Seek help/advice from Tissue Viability Nurses if a skin problem is unmanageable, becoming worse or you are unsure of the correct treatment plan
  • Promote adequate nutrition and hydration to maintain healthy skin. Dehydrated skin will be dry, and poor nutrition can affect wound healing
  • The correct use of barrier creams, selecting the right product and not over applying as this can stop continence aids from being absorbent
  • Using the correct continence products
  • Use correct equipment according to risk and maintain equipment. It is good practice to frequently check that air mattresses are functioning and to audit mattresses and cushions to ensure that they are fit for purpose. Air mattresses should be serviced frequently. Faulty or broken pressure equipment can cause more damage to the resident

Skin health is essential to the well being of older people and a fundamental aspect of good care.

It is estimated that at least 70% of older people will experience skin problems.

Wounds can negatively affect the quality of life of care home residents. Wounds can cause pain, infection, reduced mobility, depression and in severe cases sepsis and death.

Care home staff should regularly assess the skin health of their residents, promote self-care, encourage, and maintain the correct use of appropriate products and treatment plans.

Avoidable pressure damage can be prevented by implementing robust risk assessment and management plans.