18. Skin and Wound Management

The Primary goals of the skin and wound management programs are:

  • Identification and management of risk factors
  • Wound assessment with classification and management
  • Annual evaluation of the wounds and skin care program to reflect best practices
  • Enhancement of clinical knowledge in wound management
  • Enhancement of skills in the areas of prevention wound assessment and documentation

The anatomy of physiology of the skin is a tough, supple cutaneous membrane that covers the entire surface of the body. It is the largest organ system and exhibits both protective and adaptive properties.

The functions of the skin are as follows:

  • Protects underlying tissues from trauma, bacteria, and other harmful agents
  • Senses temperature, pain, touch and pressure
  • Regulates body temperature through sweat production and evaporation
  • Synthesis Vitamin D

As people age, all skin functions decline and expected changes in physiology occur as a result. Seniors have lower oxygen levels, decrease in vascularity and nutrients, loss of collagen and loss of protective cushioning effect that contribute to skin thinning and breakdown. Consequently some of the common risk factors for skin disease and breakdown include:

  • Aging
  • Dehydration
  • Diabetes
  • Drug therapy
  • Extreme obesity or thinness
  • Immobility
  • Impaired circulation
  • Urinary and fecal incontinence
  • Tissue trauma
  • Sensory impairment (pain)

For skin break down the 4 major extrinsic factors involved in the development of skin ulcers are:

  1. Pressure is defined as the force or weight produced on the skin by contacting external surface, and is the greatest in areas where the bones are closest to the surface of the skin. Pressure is usually concentrated on specific areas, particularly bony prominences.
  2. Shearing is trauma caused by tissue layers sliding against each other, resulting in the disruption of blood vessels. This leads to cell death.
  3. Friction is the mechanical force exerted when the skin is dragged across a coarse surface such as a bed linen.
  4. Moisture is the term used to describe skin damage that occurs as a result of prolonged exposure to a resident’s skin to various sources of moisture including urine, stool, and perspiration.

Pressure areas where tissues are prone to skin breakdown include:

Pressure Areas

The extrinsic factors pressure, friction, shearing and moisture that are responsible for skin breakdown can be prevented. Some of the things that health care workers can do to reduce the risk of irreversible damage to the skin are as follows:

  1. Turn and reposition the resident at least every 2 hours.
  2. For wheelchair-bound residents, have the residents shift their weight every 15-30 minutes –if unable health care workers can reposition every hour).
  3. Always use a turning/lifting sheet when repositioning.
  4. Keep the head of the bed at 30 degrees or lower.
  5. Use heel booties/elbow protectors when indicated, pillows can also be used to relieve pressure.
  6. Careful cleansing of skin after incontinent episodes, use appropriate brief size and check briefs often to ensure dryness.
  7. Use devices that are available and enable independent positioning.
  8. Consult with OT or PT for therapeutic positioning.

There are intrinsic risk factors which contribute to skin breakdowns and ulcerations. These major intrinsic factors include:

  • Mobility
  • Age
  • Poor nutritional status
  • Physical factors

Mobility can be impaired due to the loss of sensitivity, mental deterioration physical disabilities that prevent movement, pain, and restraints.

Age affects the metabolic processes slow down, sweat gland activity is reduced which causes drier skin. Skin is less elastic and has reduced collagen and decreased circulation. Age can put the elderly at greater risk for skin breakdown and can reduce the speed of pressure ulcer closure or healing.

Poor nutritional status may lead to dehydration, anemia and inadequate supply of reserves needed for healing. Nutritional intake deficient in protein and vitamins or calories may cause malnutrition with the result of weight loss, the muscle bulk or padding that is used to protect against injury is reduced.

Physical Factors that may contribute to skin breakdown are cardiovascular disease, altered mental status, spasms, contractures, incontinence, acute illnesses, and gastrointestinal changes.


Some of the things that health care workers can do to reduce the risk of skin breakdown with intrinsic factors include the following:

  1. Encourage the highest degree of mobility (e.g., having a resident walk to washroom if indicated in care plan).
  2. Encourage adequate food and fluid intake for body weight. Report to supervisor any decrease in appetite. Document all intake adequately.
  3. Provide nutritional supplements as ordered by the registered dietician or physician.
  4. Observe overall skin integrity every 24 hours
  5. Bathe resident with warm water and re-moisturize skin after bathing

Skin breakdown can be attributed to trauma (skin tears), surgical procedure, venous stasis ulcers, arterial ulcers, and pressure. The most common skin breakdown observed in long-term care homes is skin tears and pressure ulcers.

NOTE: Remember that excellent basic nursing is the best thing that prevents most pressure ulcers.


Skin tears definition is a traumatic wound that often results from external friction and or shearing forces such as removal of tape that separates the epidermis from the dermis layer of skin. Skin tears can be caused by a trauma from a fall, improper transferring, and improper handling of fragile skin, self-inflicted trauma to the skin or assaults between residents causing injury. There is a standardized classification system for skin tears.

skin-tear-1Skin Tear –Category 1

(Skin without tissue loss)-the skin flap can be approximated so that no more than one millimeter of the dermis is exposed.

skin-tear-2Skin Tear –Category II

(Skin tear with partial tissue loss)-Partial thickness in which the 25 % or less of the epidermis flap is lost and at least 75% or more of the dermis is covered by the flap

skin-tear-3Skin Tear-Category III

(Skin tear with complete tissue loss) –Skin tear with complete tissue loss, the epidermal flap is absent.

For skin tears, documentation always includes the following:

  • Classification of skin tear Category I, II or III
  • Location of skin tear
  • Size of skin tear
  • Wound bed condition (e.g., Exudate, % of viable tissue, % on non- viable tissue
  • Peri-wound skin color and condition (e.g., edema, maceration, and induration)
  • Approximation and condition of wound edges (open or closed)


When a healthy person shifts his weight while lying or sitting, the relief of pressure allows blood to flow back into starved tissue, giving the skin a red flushed appearance. The first sign of a pressure ulcer is a red mark that will not go away. Unrelieved pressure can lead the stages of ulcer development beginning with the red mark that won’t blanch and ending with deep tissue destruction extending through the subcutaneous tissue. The most severe form can involve muscle layers, joint, and even bone. Pressure ulcers can be defined as a localized injury to the skin and or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shearing. The wording stage, grade are most historically used. There are 5 stages of Pressure ulcers.

Staging of Pressure Ulcers

ulcer-1Stage I – Non-blanchable erythema or reddened area of intact skin that does not return to normal after 30 minutes of pressure relief.

ulcer-2Stage II – Shallow, denuded area of damage involving the epidermis or the dermis. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

ulcer-3Stage III – Tissue damage or necrosis extending through the epidermis and dermis and the subcutaneous tissue, which may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without, undermining or adjacent tissue.

ulcer-4Stage IV – Full-thickness skin loss with extensive tissue damage and tissue necrosis extending to muscle, tendon, bone or bone capsule.

ulcer-5Stage V – Wounds covered with black eschar and wounds in which it is impossible to fully visualize
the wound bed. Also referred to as an “unstageable” wound.

Use the following guide to document the observations with each pressure ulcer:

Stage the Ulcer – Stage 1-X

Undermining – Use a clockwise sweep when describing where the undermining is (i.e. 12 o’clock or 3 o’clock)
Necrotic Tissue Type – Any necrosis visible, slough present, adherent soft black eschar etc.
Necrotic Tissue Amount – Any necrosis visible, use % of the wound (i.e. less than 25% of wound bed or 75% of wound covered
Type of Exudates – Serosanguinous, serous, purulent, fouls smelling Amount of Exudates – None, scant, small, moderate, large Surrounding Skin – Inflamed or macerated
Pain – Scale 1-10, objective or subjective