Prevention of Skin Breakdown

1

• Prevention of Skin Breakdown
• Inspect daily ( broken skin, ischemia, hyperemia
• Change position q2h
• Message skin pressure prone areas
• Lubricate dry unbroken skin
• Apply lotion to bedridden boney areas
• Cleanse with warm water and mild soap
• Protect elbows and heels
• Keep linen wrinkle free and clean
• Encourage balanced diet and adequate hydration
• Do ROM

2

• Staging of Pressure Ulcers
• Defined by National Pressure Uler Advisory Panel
  as any lesion caused by unrelieved pressure
  resulting in damage to underlying tissue. Located
  over bony prominence. Four mechanical factors
  contribute to the development of pressure ulcers
  pressure, friction, shearing and moisture.
  Elderly clients are affected most, people who
  have prolonged periods of immobility
• Pressure Ulcer Staging
• Stage I Nonblanchable erythema of intact skin,
  the heralding lesions of skin ulceration
  

3

• Skin temperature (warmth or coolness)
• Tissue consistency ( firm or boggy feel)
• Sensation (pain, itching)
• Ulcer appears as a defined area of persistent
  redness in a lightly pigmented skin, whereas in
  darker skin tones, the ulcer may appear with
  persistent red, blue or purple hues

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• 2. Stage II Partial thickness loss involving
  epidermis or dermis. The ulcer is
  superficial and presents clinically as an
  abrasion, blister, or hallow crater.
  Usually caused by friction or moisture plus
  pressure. Pain- ful and may have minimal
  drain- age
• 3. Stage III Full-thickness skin loss
  involving damage or necrosis of subcutan-
  eous tissue that may extend down to, but
  not through underly- ing fascia. Ulcer
  presents

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• clinically as a deep crater with or
  without the undermining of adjacent tissue.
  Usually caused by pressure plus shearing
  forces
• 4. Stage IV Full thickness skin loss with
  extensive destruction, tissue necrosis, or
  damage to muscle bone, or supporting structure
  tendons or joints capsule are examples).
  Undermining and sinus tracts may be associated
  with this stage ulcer