Which of the following are the most common causes of skin breakdown that can lead to pressure sores?
- Pressure
- Friction (shear)
- Moisture
- Inadequate nutrition
- Poor blood circulation
If you answered “all five,” you are correct.
As healthcare workers, we all bear the responsibility of helping our clients avoid skin breakdown. By identifying the causes and the risks of each individual, we can work pro-actively rather than reactively.
Pressure
Pressure is the most obvious contribution to skin breakdown. Typically, the pressure is between a bony part of the body and a hard surface, such as the coccyx and seat of a chair, the underarm and the top of a crutch, for example. However, this is not always the case, so care must be taken to observe the whole body.
Pressure may also be caused by the equipment the patients use, as with a splint, perhaps or an ill-fitting pair of shoes. The straps of an oxygen mask or ill-fitting glass frames may cause skin breakdown around the ear.
While, generally, some pressure on a skin point will not cause a problem, the amount of pressure, along with the length of time, may cause considerable harm to the skin.
Friction/Shear
Many patients who are bedridden are subjected to friction or shear forces when their caregivers are moving them or as they try to move themselves. As unintentional as this is, the result may be skin breakdown, leading to a pressure ulcer.
Typically, friction occurs when moving a patient on the bed, lifting him up to the head to be more comfortable, for example. The damage may occur on the coccyx area, but also the elbow, calves, and heels.
Moisture
Moisture that contributes to skin breakdown is generally caused by urine but may also be caused by perspiration. For example, a woman with large breasts who perspires heavily could end up with irritation and redness between the breast and the torso. All patients who are incontinent of urine and faeces, particularly liquid faeces, have a high risk of developing skin breakdown.
Inadequate Nutrition and Hydration
A patient who is malnourished will have a difficult time maintaining healthy skin integrity. Adequate nourishment for proper wound prevention and/or for healing includes proper intake of protein, carbohydrates, fats and minerals.
It is important to keep in mind that malnourishment is not always obvious. A patient does not have to appear anorexic and can be quite large, in fact. Patients who are at risk of malnutrition include those who have difficulty chewing because of ill-fitting dentures, or missing or bad teeth; dysphagia; difficulty feeding themselves; and those who are taking certain types of medication that can interfere with food absorption – to name a few.
Hydration is another issue that must be addressed with our patients. They may not always be able to ask for water or something to drink, so we must ensure that they get adequate amounts of fluid, not just at meal times, but throughout the day – even more so when the weather is warm. Well-hydrated skin will be tougher to break down.
Poor Blood Circulation, Chronic Illnesses
People with chronic diseases, such as diabetes, are known to have problems with their circulatory system. If blood cannot be delivered to the peripheral tissues, then the skin cannot be adequately nourished. Without this nourishment, the skin becomes prone to breaking down and has a much more difficult time rebuilding itself.
Some medications for chronic illnesses can either affect the skin, such as can happen with corticosteroids, or they can affect the nutritional status.
Other Causes of Breakdown
Occasionally, our patients become injured because of other events. A lady wheeling past a cart may strike her arm lightly but end up with a skin tear. If this skin tear is not treated properly, it could develop into a sore requiring more extensive care. A man who is being helped into a chair may strike his shin on the chair leg or edge of the bed, causing a bruise and small