The Importance of Skin Integrity and Pressure Relief

Ashleigh Cole (100616145)

Durham College

FLPA Field Placement II Taunton Mills

Rahim Virji
The Importance of Skin Integrity and Pressure Relief

Skin integrity is an essential part of maintaining a healthy body, the skin is a humans most
vulnerable organ of the body and the first defense from micro organisms (Bryant, Rolstad
2001). When the skin is jeopardized it leaves the body vulnerable to disease and degeneration
(Fore, 2006). Skin integrity can start to decrease with age and as the body is slowly
deteriorating, and its important to consider nutritional diets, environmental factors, and
pressure relief to ensure healthy, strong skin is maintained (Fore, 2006). This is essential for
long term care facility staff to understand because 70% of the older population suffer from a
skin condition of some sort (SHKN, 2014).

Pressure Ulcer

Pressure ulcers or, often referred to as bedsores, can occur when there is skin breakdown to a
part of the body due to prolonged periods of pressure on the area. This happens when
someone is remaining in the same position for too long, these can range from mild to severe,
but can be a very preventable injury if there is pressure relief, redistribution, and repositioning
often (Mayo Clinic, 2017). If these things do not occur and the sore continues to progress, they
can lead to skin and/or bone infection. Common areas that develop these sores are bony
prominences where the bone is close to the surface of the skin, and put under high pressure,
see figure 1.1 to see these pressure points on the body (Mayo Clinic, 2017). There are many
reasons why someone may be at risk for a pressure sore, some risk factors may be
uncontrollable, but others can be prevented and changed to better their health. People who
have paralysis, spinal cord injuries, stroke, or conditions where they have little to no movement
of the body are at an extreme risk for pressure ulcers because they are unable to weight shift or
reposition themselves independently (WebMD, 2017). As people age, their skin begins to lose
its elasticity and become more at risk for pressure sore, but if their skin is kept care of and they
live a healthy lifestyle then they can lower their risk of skin injury (WebMD, 2017). Making poor
life choices can lead to decreases skin integrity and can raise a person’s risk of getting a
pressure ulcer, this could be having poor diet and nutrition, smoking, and living a sedentary
lifestyle. These things can be prevented and by living a healthy lifestyle it can not only improve
skin integrity, but also quality of life (WebMD, 2017).

Figure 1.1

Stages of Pressure Ulcers

There are four stages of pressure sores and all can be very much prevented.

Stage One

Stage one is the mildest, it only effects the first layer of skin and can present as a rough red
spot on the skin. Recovery for this stage usually takes 2-3 days, but if not taken care of will
progress into further, more painful stages of pressure ulcers.

Stage Two

Stage two is when the sore breaks through the skin and presents as an open wound. There may
be swelling, pus filled blisters, and quite a lot of pain and discomfort. A stage two sore can take
up to three weeks to heal and must be closely monitored.

Stage Three

Stage three pressure ulcers break through not only the second layer of skin but into the fat
tissue as well. This type of ulcer will have a strong odor and may show signs of infection such as
pus, heat, and drainage. At this stage their may, be skin around the ulcer that has died which
will look black.

Stage Four

Stage four is the most severe stage of a pressure ulcer, at this point there is potential for
muscle and ligament damage, and bone, tendon, and muscles may be visible to the eye. The
sore will have dead skin and have a strong odour, this could take months to begin to heal, and
surgery is a possibility. Below is figure 1.2, an animated picture of each four stages of a pressure
ulcer.

Figure 1.2

Preventative Measures

Even if someone has yet to have a skin injury, if their skin integrity is decreasing then certain
precautionary measures should be put in place to safe their skin. The health care team needs to
be aware and educated on risks and ensure that repositioning is being done on schedule to
ensure the pressure is being relieved (RCH, n.d). Repositioning should be done at least once
every two, or if possible once an hour, and if the person is able to weight shift independently
then they should be encouraged to do so every 15 minutes (Wantanabe, Laurie, 2014). The use
of assistive lifting devices such as sliding transfer boards, slide sheets, or hoist to prevent
friction of the skin tissue and minimize injury. Using the right wheelchair and wheelchair
cushions can help to ensure that the patient or client is getting the right amount of support and
comfort to ensure they are relieving pressure on areas that are in high risk of sores (RCH, n.d). A
health care professional should always be aware of the patient’s risk of skin injury and routinely
scanning the body for any signs and symptoms of pressure ulcers, if there are any then they
need to be documented and observed, immediate treatment should be started (RCH, n.d).

Treatment Options

Approximately 70 percent of superficial and will heal with non-operative methods, with
thorough medical management surgery can be avoided and a patient can have a full recovery.
The main principles of recovery for these pressure sores and skin injuries include reduction of
pressure, adequate debridement of necrotic and devitalized tissues, control of infection, and
meticulous wound care management.

Heel Pressure Sore Products

There are many products that have been created and developed by health care professionals to
help treat heel pressure sores and wounds (Vitality Medical, 2015). The key to healing a
pressure sore is taking of the pressure to stop friction and pressure on the area, which will
allow it to heal. These products can start before the pressure wound ever occurs, such as heel
guards and boots that protect the heel and alleviate pressure, and increase comfort. Figure 1.5
shows an inexpensive heel boot that can help prevent a sore from occurring. If these steps have
not been taken, and a pressure would occurs, than there are products that can help. These
products elevate the foot and protect the heel (Vitality Medical, 2015). These products can start
at inexpensive such as a foot elevator, that go around the lower leg to prevent the heel from
touching (seen in figure 1.6). These products can be more expensive and high tech such as the
Posey Deluxe Podus BootTM (seen in figure 1.7) (Vitality Medical, 2015).
Figure 1.5 1.7
Figure 1.6

Elbow Pressure Sore Treatment

As well as heel protectors, there are protectors and equipment for many other areas that are
high risk for skin breakdown and injuries (Vitality Medical, 2015). There are many different
products made to prevent sores on the elbow, and to help treat the elbow. Figure 1.8 is an
example of an elbow protector, this is an example of an inexpensive product, but they can
range in prices. This product, as many others, can be dual purpose (Vitality Medical, 2015).
These protective pads work as both an elbow protector, as well as for the heel (Vitality Medical,
2015).

Figure 1.8
Assessing Skin Integrity

Assessment of the skin should be conducted when a patient is admitted for the first time in a
new facility, or even if they have been transferred onto on another floor in the same facility or
hospital (Fraser, 2017). A skin assessment should look at the colour of the skin, if it is red from
being sore, or possibly black due to dead skin. They would consider the temperature of the skin,
either warm or cold, this could potential for lack of blood flow, or heat from friction and
shearing. Moisture is an important consideration when assessing the skin, high moisture can
increase risk of skin infection and breakdown (Fraser, 2017). The location of these
abnormalities are important because if they are in specific areas that are of high risk, the
patient or client could be in danger of skin breakdown and disease (Fraser, 2017). The assessor
would look and feel at the texture of the skin, such as if it feels dry, thin, or leathery. Finally,
they would look at overall skin integrity, if there is any blisters, sores, or pressure injuries. All
these components must be put into consideration before making a final decision. When a
decision is made the health care team would look at both preventative and management care
plans for the patient (Fraser, 2017).

Braden Scale for Predicting Pressure Sore Risk

Many hospitals use the Braden Scale as an initial skin assessment to determine their risk of a
skin injury, this should be performed within the first 24 hours of hospital admission (NYGH,
2006). The assessment starts with a head to tow skin assessment and potential or actual
compromising of the skin integrity (NYGH, 2006). Following the parameters of the test pick the
number with the best depiction of the patient, and total the numbers to calculate their
score(NYGH, 2006).

Scoring:

20+= low risk

16-20= medium risk

11-15= high risk

Below 10= extremely high risk

Based off of their score the interdisciplinary team working with the patient can develop and
implement a care and management plan following the Skin Integrity Guideline (NYGH, 2006).

Wheel chairs

The importance of Wheelchairs

It is important to ensure that a client has the right wheelchair that fits their needs and body like
a glove. A client needs to have the perfect fitting wheelchair, that requires a lot of
measurements and numbers to ensure they will be safe and protected. Below is a diagram
(figure 1.9) with all the measurements to properly fit someone with a wheelchair. If a
wheelchair does not fit a person perfectly it can cause them to have many issues such as skin
breakdown and pressure ulcers, muscle atrophy, and chronic pain. An Occupational Therapist in
a long term care facility often is in charge of assessing clients, requesting a device, and
measuring and adjusting them to fit the clients needs.

Figure 1.9
Tilt and Recline Wheelchairs

Some wheelchairs have tilt function, and some have reclined, other wheelchairs may have both.
Tilt wheelchairs improve pressure relief and weight distribution, they can also help maintain
range of motion (Wantanabe, Laurie, 2014). Recline does not have as much pressure relief than
the tilt function but allows some pressure relief as well as comfort for the patient. Recline is
when the back of the wheelchair moves front or back increasing and decreasing the angle of
the chair, where as the tilt can stay at the same angle but moves the seat backwards to relieve
pressure of gravity and weight shift as it changes its centre of gravity. A patient with this type of
wheelchair should be repositioned every two hours (Wantanabe, Laurie, 2014). This can be
challenging for staff to do when in a facility, such as long-term care, but should definitely be
repositioned as much as possible. The wheelchair must be at least 30 degrees tilt in order for
there to be significant pressure relief off of the ischial tuberosities (Wantanabe, Laurie, 2010).

Wheelchair Cushions

When we sit, only one third of the body's surface is supporting all of its weight, blood flow is
restricted. Every client is different, and has different needs, therefore will require a different
type of cushion. There are many different types of cushions, and each type of cushion has its
own advantages and disadvantages. Below is a list of the main types of cushion used for
wheelchairs, and the advantages and disadvantages for each cushion.

Type of Cushion Advantages Disadvantages

Foam  Variety of densities.
 Foam can adapt to any shape,
has even support, and spreads
pressure.
 An inexpensive cushion.
Gel  This cushion replaces the
consistency and support of the
 Materials wears out
quickly, and has to be
replaced more often then
other materials.
 When the gel pushes to
the side by weight often
 atrophied muscle and is usually
attached to a foam base.
 This type has excellent
pressure distribution and
comfortable for user.
Air or Dry Float  This cushion is lightweight and
waterproof.
 Designed to spread pressure
evenly so that the skin’s
pressure points get adequate
relief.
 Durable, and easy to clean.
(Mobility Advisory, 2017)
Urethane  This cushion is designed is
Honeycomb hexagon cells similar to a
beehive and distributes the
weight evenly throughout
cushion.
 This type is great for protecting
against skin breakdown
because it prevents the
referred to as “bottoming
out”, and then can
decrease the pressure
distribution.
 It is much heavier then
other types
 There is a risk of the gel
leaking out, which can
hard to clean.
(Mobility Advisory, 2017)
 The biggest drawback is
that the cushion needs to
be routinely checked for
air pressure and requires
the most maintenance.
 Caregivers or staff are
often uneducated on how
to upkeep the pressure
levels of the cushion.
 This cushion can feel less
stable than others.
 This cushion is more
expensive the other
types.
 May lose shock
absorbency qualities over
time.
(Mobility Advisory, 2017)
 moisture from collecting, it is
also very light weight and
durable.
 Best of all this cushion is that it
is washing machine and dryer
safe.
(Mobility Advisory, 2017)

Pressure Mapping

Pressure mapping is a tool used by occupational, and physiotherapists, and many other
healthcare professionals to assess pressure distribution in a more objective way. This a new
advancement in technology that has greatly improved skin assessment and analysis of pressure
distributions (Wound Care Advisor, 2017). To use it, you place a thin, sensor mat on a
wheelchair seat or a mattress surface. When your patient sits or lies on the mat, a computer
screen displays a map of pressures, using colors, numbers, and a graphic image of the patient.
The colours on the imaging translate to how much pressure there is in that area, hot colours
such as red, orange, and yellow mean there is more pressure, and the cool colours like blue and
purple mean there is less pressure in those areas(Wound Care Advisor, 2017). These systems
give both health care professionals, as well as patients, a visual representation of their skin
assessment, and can be easier for patients to comprehend. Pressure mapping is a very
advanced piece of equipment, but as with everything, there are also some drawbacks. These
machines can have inconsistencies in how they present the images, based on who has
manufactured they equipment (Wound Care Advisor, 2017). These machines can also have
defects and visual drifts, so consistent up keep and maintenance is required. Even with the
drawbacks, this piece of equipment provides crucial information to help prevent pressure sores,
and create a treatment plan specific for the clients needs. Figure 2.2 is an example of a pressure
mapping image of the bottom of the foot (Wound Care Advisor, 2017).
 Figure 2.2

Positioning Clocks

Positioning clocks are a great way to ensure that someone who is of high risk of skin breakdown
is getting repositioned routinely to prevent any breakdowns or sores. This is a great treatment
strategy to prevent ulcers, but also to treat and heal a pressure sore or ulcer (Safe Moves, n.d).
A position clock can be individualized to the positions that are most suitable for them, and can
be as specific as adding in measurements of degree, or any information that a staff member or
caregiver may need to know. These clocks can have descriptions of how to move the patient,
pictures to demonstrate what the position should look like, and even colour coordinated to
make it easy to understand (Safe Moves, n.d). These clocks have times to certain positions, so
that the caregivers or staff can follow the clock, this enhances communication so that there is
little confusion about when there was a last position change, which position needs to come
next, and at the right time. See the figure below (figure 1.4) which shows an example of a
position clock that helps enhance skin integrity and ensure regular pressure relief (Safe Moves,
n.d). The clock in figure 2.0 is Turning Clock EZTM, these clocks can be purchased online from the
company Safe Moves, and is a very high end position clock. These clocks can be purchased
online, for a cost of course, but can also easily be made at home or in a long term care facility at
a very low cost. All that is needed is cardstock, markers, construction paper, and a pin with a
back, or even an eraser to stick in the pin. Figure 2.1 shows a position clock that is simple and
easy to create. This is a strategy that can be easily implemented, and easy to use in a home
setting, hospitals, or at long term care facilities (Safe Moves, n.d).

Figure 2.0
Figure 2.1
 References
Fore, J. (2006). A review of skin and the effects of aging on skin structure and function.
Retrieved on 2017-09-27 from: https://www.ncbi.nlm.nih.gov/pubmed/16980727

Bryant, R, Rolstad B (2001). Examining threats to skin integrity. Retrieved on 2017-09-27 from:
https://www.ncbi.nlm.nih.gov/pubmed/11890081

Wantanabe, Laurie (2014). Having Both Functions on the Same Wheelchair Can Yield Clinical
Benefits -- But Opposition from Payors. Retrieved on 2017-10-01 from:
https://mobilitymgmt.com/articles/2014/11/01/tilt-recline.aspx

Wantanabe, Laurie (2010). Time to Tilt! Retrieved on 2017-10-01 from:

https://mobilitymgmt.com/articles/2010/02/01/time-to-tilt.aspx
figure 1.3 http://www.spinlife.com/Sunrise-/-Quickie-Quickie-LX-Custom-Custom-Lightweight-
Wheelchairs/spec.cfm?productID=217

WebMD (2017). What Are the Stages of Pressure Sores? Retrieved on 2017-10-01 from:
http://www.webmd.com/skin-problems-and-treatments/pressure-sores-4-stages#2

Pressure sore figure 1.1 https://www.physio-pedia.com/File:Pressure_sore.jpeg

Mayo Clinic (2017). Bedsore (Pressure Ulcers). Retrieved on 2017-10-02 from:

http://www.mayoclinic.org/diseases-conditions/bed-sores/home/ovc-20315615

WebMD (2017). Pressure Sores- Topic Overview. Retrieved on 2017-10-02 from:

https://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores-topic-overview#1
Figure 1.2 : http://annals.org/aim/fullarticle/1700644/pressure-ulcer-treatment-strategies-
systematic-comparative-effectiveness-review
RCH (The Royal Children’s Hospital Melbourne) (n.d). Pressure Injury Prevention and
Management. Retrieved 2017-10-02 from:
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_
and_Management/
SHKN, Seniors Health Knowledge Network (2014. Overview for Skin Integrity in Long Term Care
Setting. Retrieved on 2017-10-04, from: http://sagelink.ca/skin_integrity_overview_ltc_2014

NYGH, North York General Hospital (2006). Retrieved on 2017-10-04, from:

http://seniorfriendlyhospitals.ca/files/North%20York%20Gen%20Hosp%20Policy%20-
%20Braden%20Scale.pdf

Fraser, B (2017). Healthtimes: Aging Skin and The Importance of Skin Integrity Assessment.
Retrieved on 2017-10-04, from:
https://healthtimes.com.au/hub/aged-care/2/practice/bf1/aging-skin-and-the-importance-of-
skin-integrity-assessment/2/

http://physicaltherapy.med.ubc.ca/files/2012/05/Occupational-Therapy-Skin-Care-Guideline-
Final-July-08.pdf

Mobility Advisor (2017). Wheelchair Seat Cushions. Retrieved on 2017-10-09, from:

http://www.mobility-advisor.com/wheelchair-seat-cushions.html

Safe Moves (n.d). Safe Moves Turning Clock EZ Introducing a break though in Wound care
Prevention and treatment for Pennies a day. Retrieved on 2017-10-11, from:
http://www.safemoves.ca/turning-clock-ez

figure 1.4 http://www.safemoves.ca/turning-clock-ez

Figure 1.5 http://www.ahutton.com/cgw/art-Turning.htm
Vitality Medical (2015). Pressure Ulcer Treatment - Ulcers and Bedsore Treatment. Retrieved on
2017-10-23, from: https://www.vitalitymedical.com/pressure-ulcer-treatment.html ALSO FOR
FIGURES 1.5, 1.6, 1.7, 1.8,

Figure 2.2 http://slomotionshoes.com/wp-content/uploads/2013/12/fscan-Cropped1.png

Wound Care Advisor (2017). Pressure Mapping: A new path to pressure-ulcer prevention.
Retrieved on 2017-11-06, from: https://woundcareadvisor.com/pressure-mapping-a-new-
path-to-pressure-ulcer-prevention/

Emedicine (2017). Pressure Injuries (Pressure Ulcers) would care treatment and management.
Retrieved on 2017-10-30, from: https://emedicine.medscape.com/article/190115-treatment