The skin is the largest organ of the body and it becomes less resilient with aging, predisposing "at risk" individuals to cutaneous breakdown. An abundance of evidence has documented the human suffering from pressure ulcers and the increased burden of care. Despite the advent of advanced therapies for pressure ulcers, this month's continuing education article, "Skin Care and Pressure Ulcers," on page 421 reminds us that there are simple preventative measures to address dryness, maceration, friction, shear, and pressure. A multiprofessional approach is often required to optimize the skin integrity and increase the threshold for skin damage. However, regular assessment and examination of the skin is a fundamental critical step to detect early skin changes and forestall further deterioration.

Adequate moisture is crucial to maintain skin integrity. The stratum corneum normally has 10% to 15% moisture content bound to the scale on the surface of the skin by the natural moisturizing factor. When the moisture content drops below 10%, the skin becomes dry, cracked, and fissured, compromising the barrier function and leading to an increased susceptibility to injury. As a solution, hydrating creams or lotions that contain natural moisturizing factors (eg, urea or lactic acid) can increase skin surface water-binding capacity, whereas lubricating creams or ointments can trap skin surface moisture.1 The ideal time to apply moisturizers is immediately after bathing while the skin is still damp, but not wet. As a general rule, avoid potential allergens in moisturizing products, including perfumes and other unnecessary additives.

In some cases, the skin can be too damp or macerated from the damaging effect of feces and urine. Incontinence products often contain contact irritants, as well as high fluid content, that can cause maceration. The macerated skin is weakened, thus compromising its barrier function and increasing its susceptibility to bacterial damage and other insults. The judicious use of skin barriers (eg, zinc oxide ointment, dimethicone, film-forming liquid acrylates, or petrolatum) can minimize damage, supplemented with superabsorbent briefs, prompt incontinence treatment, and meticulous skin care. Some selected patients may benefit from the use of condom catheters, catheterization, or fecal-collection devices. Proactive care can prevent incontinence-associated dermatitis that may be mistaken or associated with pressure ulcers.

As part of comprehensive skin care, the management of pressure, friction, and shearing forces must be considered. Appropriate pressure management should include all sitting and lying surfaces, such as the sacrum, heels, and medial aspects of the knees. Recent evidence suggests that the provision of a pressure management cushion to residents who are first admitted to long-term-care facilities increases the number of pressure ulcer-free days and decreases the overall incidence of pressure ulcers.2

Addressing friction and shear can be challenging. As the continuing education article indicates, friction and shear often occur during repositioning and transfers. It is recommended that the patients need to be lifted clear of the bed, not dragged, when repositioning. This potential for skin injury highlights the need for the use of safe patient-handling techniques and repositioning equipment (eg, repositioning slings or glide sheets). Simple mechanical devices reduce friction and shear, protecting staff and caregivers from musculoskeletal injuries.

Every patient is entitled to simple preventative measures. Clinicians must identify the cause leading to skin breakdown and patient-centered concerns as an integral part of the loss of skin integrity including the development of a pressure ulcer.

REFERENCES