The skin is the body’s largest organ, serving as a primary defense against infection and injury. When mobility is limited, this defense can be compromised, leading to skin breakdown. This condition primarily encompasses pressure injuries and moisture-associated skin damage (MASD). Pressure injuries occur when continuous pressure restricts blood flow to tissue, typically over bony prominences, causing tissue death. MASD results from prolonged exposure to moisture sources like urine, stool, or sweat, which softens the skin and makes it vulnerable to erosion. These injuries are preventable, but once formed, they can lead to complications such as pain, extended hospital stays, systemic infection, and increased mortality.
Identifying Patients At Risk
Accurately identifying vulnerable individuals is the first step in preventing skin breakdown. Nurses assess several factors that increase susceptibility to tissue damage, including limited mobility and reduced sensory perception. An inability to reposition or feel discomfort from sustained pressure significantly raises the risk of injury.
Mechanical forces like friction and shear also contribute to risk, often occurring when a patient slides down in bed or is pulled across linens. Systemic factors such as poor nutritional status, dehydration, and excessive skin moisture undermine the skin’s resilience. To standardize this process, nurses use validated risk assessment tools, most commonly the Braden Scale.
The Braden Scale assesses six specific criteria: moisture, activity, mobility, nutrition, friction, and shear, to assign a numerical score. A lower score indicates a higher risk of developing a pressure injury, signaling the need for comprehensive preventative interventions. This standardized score provides a clear, objective measure that guides the level of preventative care required.
Strategies for Pressure Relief and Repositioning
Relieving the mechanical forces of pressure, friction, and shear is the most direct nursing intervention to prevent skin breakdown. Pressure compresses tissue between a bony prominence and an external surface, while friction is the rubbing of skin against a surface, and shear occurs when tissue layers slide over one another. Nurses must implement protocols that directly counteract these forces.
The practice of regular repositioning is fundamental, typically following a schedule of turning patients in bed at least every two hours. Frequency is individualized based on a patient’s skin tolerance and the type of support surface used. When repositioning, a 30-degree lateral side-lying position is preferred over a 90-degree position, as it avoids direct pressure on the hip’s greater trochanter.
Avoiding dragging or pulling the patient across the bed sheets is paramount to prevent friction and shear injuries. Nurses must use proper lifting techniques and assistive devices, such as slide sheets or mechanical lifts, to raise the patient clear of the surface before moving them. When raising the head of the bed, a slight knee bend helps prevent sliding, which causes shear force on the sacrum. For patients sitting in a chair, repositioning should occur at least hourly.
Specialized support surfaces provide mechanical protection by redistributing the pressure load. These surfaces can be non-powered (e.g., high-density foam mattresses) or powered (e.g., alternating pressure or low air loss mattresses). Alternating pressure surfaces cyclically shift pressure points, while low air loss surfaces maintain regulated pressure and manage the microclimate around the skin. These specialized beds are indicated when a patient cannot be repositioned frequently enough or when multiple pressure injuries are present.
Skin Hygiene and Systemic Support
Beyond mechanical pressure relief, maintaining the skin’s integrity requires meticulous attention to its external environment and the body’s internal resources. Moisture management is a primary focus, as prolonged skin exposure to fluids like urine, stool, or wound drainage can lead to moisture-associated skin damage. Nurses must promptly cleanse the skin after episodes of incontinence using gentle, pH-balanced cleansers that avoid the drying and irritating effects of harsh soaps.
After cleansing, the skin should be patted dry, and a barrier cream, ointment, or skin sealant should be applied to vulnerable areas. These topical barriers create a protective film that shields the skin from moisture and irritants while allowing it to breathe. This practice is particularly important in skin folds or areas prone to perspiration, where moisture can macerate the skin and increase susceptibility to breakdown.
Internal, or systemic, support is equally important, as the body requires adequate building blocks to maintain tissue health and repair damage. The patient’s nutritional status is directly linked to skin resilience, as poor intake of specific nutrients compromises the skin’s ability to resist and heal injury. Protein is especially important, as it is necessary for tissue regeneration and the production of collagen, which provides skin strength and elasticity.
Vitamins and minerals also play defined roles in maintaining healthy tissue structure and function. Vitamin C is required for collagen synthesis, and zinc is a cofactor for enzymes involved in cell proliferation and wound healing. Ensuring adequate hydration is another systemic factor, as well-hydrated skin retains its elasticity and is more resistant to external mechanical forces. A comprehensive approach must address both external and internal factors.