A crash course in skin trauma
Aides need skin care knowledge, too
Nurses are not the only ones who need to know more about wounds because home care aides also will be seeing more of these patients as hospitals discharge patients sooner.
Baptist Home Services of Montgomery, AL, developed a wound care program that included a one-hour inservice for aides on skin trauma.
The focus was on prevention and when to alert nurses about changes in a patient’s skin, says Susan Douglass, RN, BSN, quality assurance/ education coordinator for the agency, which is affiliated with Baptist Medical Center.
Aides see the patient more often and need to be the eyes for case managers, Douglass says. "If they can catch a pressure point from early on and bring that to the case manager’s attention, then certainly that’s the quality patient care that we’re working toward."
Douglass offers these guidelines to teaching aides about skin trauma:
1. Show them how to locate pressure points.
Douglass uses a picture book and transparencies on an overhead projector to illustrate the various points. "We try not to talk down to our nurses’ aides but not talk over their heads either," Douglass says. "So we try to keep it brief and to the point."
Douglass showed them the bony prominences and made it clear that when a patient is lying down, skin breakdown can occur.
The pressure points are as follows:
• when lying on back: heels, sacrum, elbows, shoulders, back of head;
• when lying on side: ankles, knees, hip area, shoulder, ears;
• when sitting in chair: shoulder blade, buttocks, balls of feet.
2. Describe the causes of skin breakdown.
Again, the description was less detailed than it might have been for nurses, but it covered five basic points:
• Shear and friction: Douglass explained that shear and friction may occur when a patient is moved in the bed, such as when the aide slides the patient on the sheet. This is particularly true when a patient’s skin already is traumatized.
• Moisture build-up on the skin: Aides need to be aware that a patient who is incontinent and has urine or feces on the skin for any length of time might have skin breakdown, Douglass says.
• Patient in one position for extended time: This cause involves the pressure points, the bony prominences. "A patient doesn’t need to be in one position for over two hours because then the patient’s more likely to have skin breakdowns," Douglass says. "We try to stress to our staff that with some patients, a two-hour limit is even too long to go without repositioning the person in the bed."
• Poor nutrition: Elderly patients may be preparing their own meals, but the aides need to pay attention to whether the patients are eating properly. If the patient is not eating well, then the aide should bring it to the nurse’s attention. "If the patient has only chips for lunch, then that’s poor nutrition, and it will make the patient more prone to skin breakdown," Douglass says.
• Elderly fragile skin: Some elderly patients are on medications that make their skin more fragile. Aides need to be aware of patients that have such poor skin conditions that their skin could be touched and it tears, for example. "We expect aides to be gentle with all patients, but with those types of patients, one little pulling up on the bed could pull skin off," Douglass explains.
3. Give examples of patients at risk.
While aides are not expected to make an assessment of the patient’s potential risk for skin breakdown, they should know some basic risk factors. Douglass lists these factors as follows:
• patients who are confined to bed or have poor mobility;
• patients who have circulatory problems;
• patients who have diabetes;
• patients who have severe or chronic injuries;
• patients with poor nutritional intake;
• patients who are incontinent.
4. Explain when aides should call the nurse.
This is the major service aides can provide with regard to skin trauma, Douglass says. "We certainly expect them to notify us if any of these problems are found when they’re with a patient."
Examples of skin problems include:
• During patient’s bath and skin care you notice pink area that does not fade during care.
• You see any type of skin tears, sores, or new wounds.
• Patient has wound that is draining.
• Patient or caregiver states patient has been "running a temperature," or patient has an elevated temperature.
• Patient/caregiver complains patient is incontinent.
• Patient or caregiver is refusing for patient to be turned frequently (at least every two hours).
• Patient is not eating, or eating habits have changed.
• Patient or caregiver asks questions regarding the wound or the care that is needed.
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