Chapter 15 Skin Integrity

Pressure Ulcers A pressure ulcer is a localized injury to the skin and/ or underlying tissue, usually over a bony prominence, that results from pressure, including pressure associ- ated with shear (2). Pressure ulcers can occur any- where there is prolonged pressure to soft tissue, which reduces the availability of nutrients and oxygen and eventually results in tissue death. Common loca- tions of pressure ulcers are the sacrum, coccyx, ischial tuberosities, greater trochanter, heels, iliac crests, and lateral and medial malleolus. The National Pressure Ulcer Advisory Panel (NPUAP) has estab- lished a staging system for pressure ulcers, from stage I to IV, with stage IV being the most severe (see Table 15.1, see pages 200–201 [2,3]).

Other Types of Skin Breakdown Pressure ulcers are just one form of impaired skin integrity. Surgical wounds, skin tears, diabetic foot ulcers, venous ulcers, and arterial ulcers are all common in older adults.Unfortunately, the limited research that is available on nutrition and wound care generally applies to pressure ulcers, so guidelines for nutrition management of other forms of impaired skin integrity are not known. Clinical judgment by a registered dietitian nutritionist (RDN) is required to assess and treat all forms of skin break- down, including nonpressure areas.

IDENTIFYING RISK FOR PRESSURE ULCERS

Nutrition screening and/or assessment can identify those at nutrition risk for pressure ulcers. An individu- al’s overall risk for developing pressure ulcers is often identified using the Braden Scale (4), outlined in Figure 15.2 (see pages 206–207).

Factors That Contribute to Pressure Ulcers

Pressure ulcer causes can be multifactorial (5): ● ● ●

activity and mobility limitations poor nutritional status

skin moisture (urinary or fecal incontinence, excessive sweating)

● advanced age ●

factors affecting perfusion and oxygenation (eg, hypotension, hemodynamic instability, peripheral vascular disease, diabetes);

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drugs such as steroids that may affect wound healing

● ● ● ●

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impaired, diffuse, or localized blood flow (eg, generalized atherosclerosis or lower extremity arterial insufficiency)

● ● ● friction and shear

poor general health status increased body temperature

● refusal of some aspects of care and treatment; cognitive impairment

● ●

a healed ulcer. The history of a healed pressure ulcer and its stage (if known) are important, since areas of healed stage III or IV pressure ulcers are more likely to have recurrent breakdown

NUTRITION AND PRESSURE ULCER DEVELOPMENT

Proper nutritional status is important in preventing skin breakdown. “Early nutrition intervention supports lean body reserves by preventing or delaying protein and energy deficits and their impact on pressure ulcer risk and healing” (6). Nutrients that play a role in pre- vention and treatment of pressure ulcers can be found in Box 15.1 (see page 202). The following nutri- tion-related factors can contribute to skin breakdown (7,8):

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protein deficiency, which creates a negative nitro- gen balance;

●

protein-energy malnutrition, which can result in a loss of lean body mass, unintended weight loss, and changes in immune function;

anemia, which inhibits the formation of red blood cells;

dehydration, which causes dry, fragile skin;

obesity, which can result in increased weight on pressure points; and

●

underweight, which results in a lack of padding on pressure points and may be an indicator of other nutrition issues.

Cognitive problems, difficulties with chewing and/or swallowing, and dependence on others for food and fluid intake are common in older adults and can increase risk for compromised nutritional status.