Skin is the largest organ of the human body, and as such, is jam-packed with both living and dead cells, blood vessels, free nerve cell endings, hair follicles with stem cells, vitamins, connective and elastic fibers, proteins, and adhesives.  And it is so easy to take it all for granted!  Every patient in a hospital or long-term care facility, and many community dwellers are at risk for injury to the skin.  Among the protective strategies that the NPUAP/EPUAP/PPPIA have published to help prevent pressure injuries/ulcers (PI/PU) is skin protection.[1]  While many of the strategies seem like common sense, each one bears reviewing as we conclude this section on PI/PU prevention.  The strategies are the following:

• Avoid positioning a patient with direct pressure on an existing bony prominence that is erythematous.  For example, if the left greater trochanter is noted to be red, a turning schedule would not include left side-lying; and if the patient is positioned in a wheelchair, care would be taken to prevent pressure on that side.
• Keep the skin clean and dry.  For patients who are incontinent, this may be laborious and time-consuming; however, it is a must for preventing PI/PUs.  Skin that is too moist breaks down much easier, allows more bacteria to enter the tissue, and does not withstand friction and shear.  Cleansers should be pH balanced (normal skin pH is 4.0-7.0) as they decrease skin dryness and irritation.  In addition, protective bed liners or disposable underwear should not have any plastic components. The plastic holds both moisture and heat against the skin; thereby decreasing the ability of the skin to withstand mechanical forces. 
• Avoid massage or vigorous rubbing of the skin.  While it was thought that massaging would increase the blood supply to the skin and underlying tissues, the concern is that too much force will result in damage to the skin capillaries and subcutaneous tissue.
• Patients who are incontinent of urine and feces need an individualized care plan to protect the skin.  In addition, care must be taken to position the devices and tubes so that the patient is not laying or sitting directly on them, a situation that may lead to medical device-related PI – definitely a “never-event”!  Patients who are placed on bedside commodes should not be left for long periods of time as the direct pressure on the buttocks can lead to PI.
• A barrier cream can be used on the skin to further protect the skin from excess moisture.  Moisturizers used for dry areas should not contain alcohol or perfume, both of which can dry out skin.
• Silicone-backed foam dressings have been studied both in random-control trials and in the laboratory, to determine their effectiveness in reducing the mechanical forces on areas most vulnerable to PI (sacrum, heels, trochanter) with statistically significant results in decreasing the mechanical forces between the support surface and skin, thereby reducing the incidence of PI.[2]^,[3] (See photo).  Factors to consider when selecting a foam dressing include the following:  the size and shape of the area to be protected, the most likely direction of forces which the area will be exposed to as the patient moves or is repositioned (e.g. moving the patient up in the bed will more likely produce caudal/cephalic shear), the amount of moisture the dressing can absorb without losing its integrity, the conformability of the dressing to the body part, and the amount of time the dressing can maintain its protective properties.³  Most dressings, if properly selected and applied, will be effective for 3-5 days; however, any dressing that loses its adhesiveness, becomes soaked with fluid, rolls at the edges, becomes displaced, or otherwise loses its effectiveness, should be changed.  The life of a dressing will, in some part, depend on the skill with which it is applied.  The entire dressing inner surface should be adhered to the patient skin with no “dead or empty spaces” where air and moisture can accumulate, and the edges should be smooth with minimal or no wrinkles.  If a patient is restless or the area vulnerable to a lot of friction, the edges can be reinforced with additional hypoallergenic tape to prevent them from rolling, and thereby prolong the life of the dressing.[4]  And any dressing that becomes soiled should be removed, the skin cleansed and dried, and a new dressing applied as soon as possible.

In summary, the skin should be assessed at least once a day, and an effective individualized prophylactic plan developed.  Each and every discipline involved in the patient’s care should be informed of the plan and involved in observing the skin and reporting any changes that indicate the presence of early pressure injury.

[1] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.  Available at www.internationalguideline.com/static/pdfs/NPUAP-EPUAP-PPPIA-CPG-2017.pdf.

[2] Strauss R, Preston A, Zlman DC, Rao AD.  Silicone foam dressing for prevention of sacral deep tissue injuries among cardiac surgery patients.  Advances in Skin and Wound Care. 2019;32(3):139-142.

[3] Burton JN, Fredrickson AG, Capunay C, Tanner L, et al. Measuring tensile strength to better establish protective capacity of sacral prophylactic dressings over 7 days of laboratory aging. Advances in Skin and Wound Care. 2019;32(7S):S21-S27.

[4] Weir D, Brindle CT. Wound dressings.  In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2^nd edition.  New York: McGraw Hill Education.  2019, 373-417.  Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334.