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  1. Francis, Kathleen DNP, FNP-BC, CWOCN

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SKIN INJURIES such as incontinence-associated dermatitis (IAD) and pressure injuries are increasingly monitored and benchmarked as a quality indicator for hospitals and nursing facilities.1-4 Pressure injuries are documented by Medicare- and Medicaid-certified skilled nursing facilities in the Minimum Data Set, and pressure injury incidence rates are publicly reported as a quality measure in the Nursing Home Compare website.5

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Many clinicians have difficulty distinguishing superficial skin injuries from early-stage pressure injuries because the differences can be very subtle. Mistaking IAD for an early-stage pressure injury can result in ineffective treatment and possible deterioration to full-thickness injury.6,7 This is particularly true in patients with dark skin tones because visual cues associated with these types of skin injuries may not be easy to detect.8-12 Likewise, failure to detect blanchable and nonblanchable erythema in a patient with dark skin tones may increase the patient's risk of developing a full-thickness skin injury.13


This article discusses how to differentiate, classify, and document IAD and pressure injuries with an emphasis on assessing patients with dark skin.


Correct assessment is critical

Accurate classification of skin injuries and identification of their etiology is essential to ensure that the correct treatment plan is initiated to halt the injury and support healing. Besides impacting patient care, inaccurate identification of skin injuries can negatively affect benchmarking data and payments to the facility.2,14 Many clinicians have difficulty making the correct identification because these injuries can have very subtle differences.15-19


Pressure injuries have traditionally been classified using a staging system based on depth of tissue injury. These have been revised over the years to incorporate the current understanding of the science of pressure injury pathology and etiology (see NPUAP pressure injury stages).20,21 Full discussion and description of all pressure injury stages is beyond the scope of this article, but additional information can be accessed from the National Pressure Ulcer Advisory Panel (NPUAP) website at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure.


The NPUAP staging system should be used only for injuries caused by pressure.20,22 Other skin injuries can be classified as either full thickness or partial thickness, depending on the depth of tissue damage in the wound. This discussion focuses on Stage 1 and 2 pressure injuries and deep tissue pressure injuries (DTPI) as defined by the NPUAP because these are the pressure injuries most likely to be confused with IAD.


The difficulty in differentiating Stage 1, Stage 2, or suspected DTPI from IAD has been documented in the literature as problematic, particularly in patients with dark skin.6,7,13,15,23 Improving the nurse's ability to correctly identify skin injuries can lead to better patient outcomes.


Skin deep

The skin is the most visible and one of the largest organs in the human body.24-26 Its functions include protection against physical injury, sunlight, and microorganisms; prevention of fluid loss from the internal environment; regulation of body temperature; continual reception of sensations from the environment, such as temperature and pain; and Vitamin D synthesis through the action of sunlight on the skin.27


The skin consists of two main layers: the epidermis, a superficial and thinner epithelial tissue layer, and the dermis, which is a layer of deeper and thicker connective tissue. The basement membrane zone is an interface between the dermis and epidermis. A layer of subcutaneous tissue called the hypodermis stores fat and contains large blood vessels.27


Skin thickness varies depending on its location on the body; for example, skin on the soles of the feet is thicker than the skin covering an eyelid. The amount of adipose tissue in the subcutaneous layer can also vary. The pinnae of the ears, the bridge of the nose, and the malleoli, for example, have little to no adipose tissue. As a result, skin injury in these areas can easily become full thickness even though they appear as shallow injuries.22


The skin is capable of regeneration and, under normal conditions, is strong enough to withstand minor insults without epithelial erosion.28,29 Partial-thickness injuries can regenerate via epithelial migration, leaving little to no evidence of prior injury.26,30 However, skin that's overhydrated or overly dry can be at risk for mechanical injury, such as friction, shear, and pressure. (See Differentiating friction and shear injuries.) Overhydrated skin loses its barrier function, making it susceptible to erythema and denudation from enzymes in urine and stool.25,28,31


Unique characteristics of darker skin tones include higher lipid content and the presence of a greater number of melanosomes in the stratum corneum compared with levels of lipid and melanosomes in light skin. These differences can mask erythema and may cause inflammation to appear as violet-black or black.26 Because darker skin has more melanin than light skin, assessment of blanching can also be muted, complicating identification of early skin injury.10,26


Incontinence-associated dermatitis

Moisture-associated skin damage (MASD) is defined as damage to the skin secondary to persistent exposure to moisture in the affected area.32,33 IAD, a form of MASD, has been defined as a skin injury or inflammation that presents with erythema and edema, with or without blisters, and denudation that occurs as a result of the skin's loss of moisture barrier from exposure to urine and stool.32,33 The NPUAP guidelines suggest that MASD can increase the risk of pressure injury development and this correlation has been well documented.2,17,33


Skin lesions resulting from IAD may be located on the buttocks, perineum, groins, vulva, scrotum, and perirectal area, as well as on the posterior and medial thighs.30-33 The location of injury depends on the presence of urinary, fecal, or dual incontinence and can be most severe when the patient is having frequent episodes of incontinence and exposure to liquid fecal effluent.18,28,31 Prolonged exposure to chemical irritants in urine and stool impairs the skin's protective acid mantle, thereby disrupting its "brick and mortar" barrier function.18,28

Table NPUAP pressure... - Click to enlarge in new windowTable NPUAP pressure injury staging

IAD typically presents as moist, erythematous skin irritation and inflammation with superficial epithelial edema and diffuse, irregular borders.18,28,31 IAD can also present with erosion of the epithelial layer or denudation. In addition, weeping and blistering or vesicle formation can occur.

Table Types of skin ... - Click to enlarge in new windowTable Types of skin injuries: Differential assessment

The appearance of satellite lesions or vesicles is likely due to secondary cutaneous candidiasis and is often associated with more severe cases of IAD.18,27,31,32 In patients with darker skin tones, the erythema may be subtle, appearing as a discoloration in comparison with surrounding skin.34


Patients with IAD may report a burning sensation with pain and pruritus. If exudate is present, it's often serous and weepy.33,34 (See IAD: Light skin toneand dark skin tone.)


Preventing IAD

Nursing care for patients at risk for IAD includes implementation of a structured skin care regimen, which is especially important for patients who are incontinent. Most regimens involve gentle cleansing with a soft cloth and a no-rinse cleansing formula that contains surfactants to loosen irritants, and application of a barrier ointments.31,32 See http://www.Nursing2018.com for supplemental online content, Sample skin care bundle, based on Braden Risk Tool.


Moisture barrier ointments serve to protect the skin by providing a barrier to effluent. Many barrier formulations are available; they may be petroleum-based, dimethicone-based, or zinc oxide ointments.18,28,32-34


Use of incontinence pads and briefs should also be included in an incontinence management program. Use materials that are highly absorbent and frequently change garments as needed to keep the skin dry and prevent fungal dermatitis.18,28,32,33


Differentiating pressure injuries

The NPUAP defines pressure injury as "localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. This injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may be affected by microclimate, nutrition, perfusion, comorbid conditions, and condition of the soft tissue."22


Risk factors for pressure injury can be intrinsic and extrinsic.16,21 Intrinsic factors, which come from within, include age, comorbidities, nutritional status, hypotension, elevated body temperature, immobility, and signs of stress, such as wrinkling and decreased skin turgor and elasticity.16,35 Extrinsic risk factors include environmental forces that act to cause injury, such as shear, moisture, and pressure.16,21,35


Careful and thorough skin inspection is warranted when assessing for Stage 1 pressure injury or DTPI, particularly in patients with dark skin tones.10,22 For tips and guidelines, see Types of skin injuries: Differential assessment. Updated NPUAP risk assessment tips and prevention interventions can be found on the NPUAP website at http://www.npuap.org/wp-content/uploads/2016/04/Pressure-Injury-Prevention-Point.


Assessment strategies

To differentiate skin injuries accurately, first obtain a comprehensive health history to identify any risk factors for pressure injury and/or IAD. Also ask the patient or caregiver about the patient's bathing and toileting routine.


When assessing the patient's skin, always ensure adequate lighting so you can detect subtle changes in skin color. Appropriate lighting with natural lighting, a halogen lamp, or a flashlight is especially important for inspecting dark skin tones. Avoid fluorescent lighting, which may cast a bluish tint on dark skin.10,36


Inspect the skin for slight changes in color surrounding the assessment area, and make sure you examine the area from multiple angles. Sullivan reports that hyperpigmentation may be a sign of early skin injury in patients with dark skin.11


Palpate the area for changes in temperature and texture.10,11,36 Localized heat, edema, or any change in tissue consistency, such as induration or hardness, may be a sign of pressure injury.10,22


Ask the patient to describe pain or discomfort. Pressure injuries may be painful; a burning sensation suggests IAD.10,33 When skin injury is identified, the nurse should document the injury type, characteristics, and measurements. Some facilities also document skin injuries with photographs and rely on these documentation strategies for ongoing assessment for improvement.


Working toward better outcomes

Pressure injury and IAD are common in all healthcare settings. Nurses must accurately identify and classify skin injuries to ensure high-quality patient care. This requires knowledge of normal and abnormal variations in skin tones, especially in dark skin. Armed with clinical knowledge and assessment skills, nurses are prepared to identify early signs and symptoms of skin injury and to implement interventions that will improve patient outcomes across the continuum of care.


Differentiating friction and shear injuries

Friction is defined as the resistance to motion in a parallel direction relative to the common boundary of two surfaces causing superficial skin injury when the skin rubs against another surface.2 Such injuries can easily occur when a patient is dragged during repositioning instead of being lifted.33,37 This type of injury is shallow and limited to the epidermis; it doesn't result in the ischemic skin changes associated with pressure injury.


Friction is no longer considered an etiologic factor for pressure injury, and wounds caused by friction shouldn't be classified as pressure injuries.22,33,38


Shear is defined as a mechanical force that's parallel and opposite. It's also affected by the presence of pressure and is considered an etiologic factor in pressure injury development.21,22,33,37 Deep shear force can create skin damage by the interaction of parallel movement and pressure while the body is in motion.


Shear injuries commonly occur when a patient slides down in bed. The muscle and deep underlying vessels can be stretched and compressed between the bone and support surface as the patient moves downward and the skin is held in place.21,31 This can cause deep tissue injury resulting from ischemia.31,33




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