Digital photography is a useful tool for monitoring pressure injuries and skin tears, providing visual enhancement to written assessment and management of these wounds.
Risk screening and risk assessment of skin integrity generally refer to the same process, which is used to identify patients who are at risk of developing skin problems or who have skin problems. The results of screening or assessment are used to inform the implementation of prevention and management strategies.1
As clinicians, we need to be alert to risk factors, use a recommended risk screening tool and complete a head to toe physical examination of the patient’s skin.
The following are risk factors for older people developing skin problems. We must be aware that these risk factors may be unrelated to the primary reason for the person being admitted to hospital.
- The changes that can occur to skin as it ages can affect its integrity, making it more vulnerable to damage and at a higher risk of developing pressure injuries and skin tears.
- Changes to the skin include its mechanical properties, geometry, physiology and repair, and transport and thermal properties.
Previous pressure injuries or skin tears
- Poor nutrition can result in the patient missing important nutrients and vitamins required to maintain healthy skin and assist with wound healing.
- People who are malnourished can be both underweight or overweight, which can increase the risk of skin damage, especially pressure injuries.
- Dehydration can cause a person’s skin to be less elastic, more fragile and more likely to break down.
Swallowing or dental problems
- Swallowing or dental problems can result in poor nutrition.
Balance or mobility problems
- Balance or mobility problems may cause patients to fall or knock themselves against furniture, which can cause skin tears.
- All patients who are restricted to bed or chair rest are considered to be at risk of developing a pressure injury.2
- Faecal and urinary incontinence can result in excess moisture on the skin, which can cause skin problems.
- Urine on the floor can be a hazard and can cause a slip, resulting in skin damage.
- Elevated body temperature and perspiration can increase the risk of pressure injury development.
- Patients who are cognitively impaired may be unable to:
- regularly reposition themselves
- knock themselves on furniture and cause skin tears
- care for their skin
- verbally communicate that they are experiencing pain related to a pressure injury or tear.
- These medications can cause cutaneous or inflammatory interactions and reactions:
- tricyclic antidepressants
- antineoplastic drugs
- antipsychotic drugs
- oral diabetes agents
- nonsteroidal anti-inflammatory drugs
- Having difficulties washing or drying any part of their skin (for example, contractures, folds beneath abdominal aprons or hard to reach areas between toes).
Certain medical conditions
- Hypotension (low blood pressure)
- Sensory perception disorders
- Blood circulation (for example, diabetes)
- Quality of circulating blood (for example, anaemia)
Explain the risk factors and the risk of developing a pressure injury or skin tear to the patient and their family and carer so they can play a role in preventing problems.
Screening and assessment tools
Best practice guidelines recommend conducting a structured risk screening or assessment process for all older people as soon as possible after admission (within 8 hours) and as often as required by the individual’s condition or if there is a significant change in their condition2.
If the older person has existing pressure injuries or skin tears upon admission to hospital, it is important to classify them and treat and manage them appropriately.
Use an organisational-wide agreed pressure injury risk screening and assessment tool for all people aged 65 and over3.
The most commonly used and recommended pressure injury risk assessment tools for adults are:
- Braden Scale for Predicting Pressure Sore Risk (Braden Scale)4
- Norton Scale5
- Waterlow Scale6.
For skin tears use:
Once you have identified that an older person is at risk of developing a pressure injury or skin tear complete a nutritional screen and assessment7.
A comprehensive head to toe examination of the older person’s skin will help us identify existing damage to the skin, pressure injuries or skin tears and evaluate any changes to the skin2. The skin examination should be done as soon as possible after admission (within 8 hours) and as often as required by the individual’s condition or if there is a significant change in their condition2, 3.
During the skin examination, we should make sure that:
- the room is quiet, private and has a stable temperature
- there is adequate lighting to see the skin colour properly
- fingernails are trimmed and jewellery minimised (so we don’t hurt the patient)
- we inspect all areas of the skin, especially those not usually exposed, such as the buttocks, armpits, back of thighs and feet, and pay attention to bony prominences such as the sacrum, heels and ankles, elbows, shoulders and ears
- we note other areas on the body subject to pressure from equipment such as nasogastric tubes, oxygen masks and bed rails
- we include the patient and inform them about what we are doing. Often the patient can give us useful information about what they are feeling.
“It is quite difficult if you are in bed, how can you look at your bottom for instance, and that is where you most likely to get pressure areas. It’s not easy to do that. You just sort of feel that it is not right. It feels tender.” (older patient)
Ask the patient, their family or carer about:
- past medical history, such as diabetes, peripheral vascular disease or continence problems that may affect skin quality or healing
- current medications that treat skin problems or that may have an affect on the skin condition, such as steroids
- previous skin problems
- recent changes to the skin
- any areas of pain or discomfort
- skin care routine – including the products they use, such as soap and creams
- psychological wellbeing – is the patient under any particular stresses at present?
This will help us determine the cause of any skin problems and assist in treating and managing them.
Look and assess:
- signs of dry skin, oedema, variations in skin colour, bruising, inflammation, scratch marks, jaundice, swelling, breaks, ulcers, lesions or rashes
- pressure areas for signs of potential breakdown
- general skin quality of the whole body.
Touch, feel and assess:
- texture – is it smooth or course?
- moisture – is it dry?
- turgor (swelling) – is the skin layer firm and resistant to being pinched? Does it ‘tent’ or stay in condition when being pinched? Tenting can be an indicator or dehydration or malnutrition
- temperature – is the skin hot or cold and are there variations around the body? A hot area could indicate inflammation; a cold area could indicate decreased arterial blood supply and vascular changes
- reddened areas – differentiate whether the skin is blanchable or not. Non-blanchable erythema means there is structural damage to the skin and indicates a stage 1 pressure injury. To assess, apply light pressure with your finger over the erythema for three seconds. If the area remains the same colour as before the pressure was applied, this is non-blanchable.
Smell and assess:
- if the patient is able to wash
- the condition of flexures (skin folds)
- if the patient has incontinence8,9.
Document the results
Document the results of all risk screening or assessment, including the skin assessment, in the patient’s clinical records or notes2. Use these results to develop a prevention or management plan.
1. Department of Health, Preventing and Managing Pressure Injuries, 2014, Sector Performance, Quality and Rural Health, Victorian Government, Department of Health.
2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance, Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, 2014: Perth, Australia.
3. Australian Commission on Safety and Quality in Healthcare (ACSQHC), National Safety and Quality Health Service Standards, 2011, ACSQHC: Sydney.
4. Bergstrom, N., et al., The Braden Scale for Predicting Pressure Sore Risk. Nursing Research, 1987. 36(4): p. 205-10.
5. Norton, D., R. McLaren, and A. Exton-Smith, An investigation of geriatric nursing problems in hospital, 1962, National Corporation for the Care of Old People (now Centre for Policy for Ageing): London.
6. Waterlow, J., Pressure sores: a risk assessment card. Nursing Times, 1985. 81(48): p. 49-55.
7. Acton, C., The importance of nutrition in wound healing. Wounds UK, 2013. 9(3): p. 61-64.
8. Cowdell, F., Promoting skin health in older people. Nurs Older People, 2010. 22(10): p. 21-6.
9. Finch, M., Assessment of skin in older people. Nurs Older People, 2003. 15(2): p. 29-30