The skin is the outermost covering of the human body and as the largest organ of the integumentary system, has up to seven layers of ectodermal tissue protecting muscles, bones, ligaments and internal organs. The skin has multiple functions such as protection, providing a barrier to infection, regulating body temperature, plus sensory receptors to help us sense and respond to the world around us (Beldon, 2010).
The skin is often underappreciated for its amazing ability to do so many things to keep us healthy and safe. Consequently, we need to be having open and honest conversations with our patients and long-term care residents about the importance of good skin care to reduce the risk of skin damage and maintain a good quality of life (Beldon, 2010).
One key aspect of promoting skin health is to ensure nutrition and hydration is regularly assessed as part of an individualised plan of care for our patients and residents. Good nutrition and hydration is essential for optimum skin health and to reduce the risk of pressure ulcer development (Fletcher, 2020).
“A pressure ulcer (figure 1) is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin, or an open ulcer and may be painful.” (NHSI, 2018).
It is believed that poor nutrition and hydration greatly increases the risk of pressure ulcer development (British Dietetic Association BDA, 2018). In the UK alone, is thought over 3 million people are at risk of malnutrition (Allied Health Professional, AHP, 2012). The impact of malnutrition can be catastrophic, causing delayed wound healing, increased risk of infection, reduced immunity and longer hospital stays (BDA, 2018). Both underweight and overweight patients/residents are at an increased risk of developing a pressure ulcer. Those who are underweight will have less cushioning resulting in their bony prominences being more exposed, while those who are overweight can be less mobile due to excess weight being carried through their pressure areas, thus increasing the risk of pressure ulcer occurrence (BDA, 2019).
The National Institute for Health and Clinical Excellence (NICE) (2006) recommends that to assess a patient/resident’s risk of malnutrition, a screening tool should be carried out on admission. The most commonly used is the malnutrition screening tool (MUST) (Figure 2) which can be downloaded here.
The MUST tool enables those in our care who are malnourished, are considered to be at risk of malnutrition, or those who are clinically obese to be quickly identified and then referred to a Dietician for further support and a full comprehensive assessment (BAPEN, 2011)).
Nutritional assessment is essential in patients/residents who are at risk of pressure ulcer development to ensure an individualised nutritional care plan is implemented that best meets their needs (Reber et al., 2019).
When considering our residents’ and patients’ intake, it is also essential we also consider their hydration needs, ensuring they are drinking enough fluid, as the skin needs fluid to remain healthy and avoid becoming dry and fragile. Wounds also require a good fluid intake to heal (Ousey et al., 2016).
Nutrition and hydration is everybody’s business and supporting our patients’ and residents’ nutrition and hydration needs should be undertaken by the Multi-Disciplinary Team as a whole (Fletcher, 2020). Each person within the team has their own skillset which can be used to create a 360° comprehensive plan of care to achieve a better outcome for the patient or resident.
Typically, a Multi-Disciplinary Team can include:
Doctor who will assess the patient for any medical reason that may be affecting their nutritional status and then prescribe medication if required.
Pharmacist willsuggest supplements that may be nutritionally beneficial.
Dietitian will complete a full nutritional assessment. This enables them to identify food and fluid requirements and make recommendations.
Speech therapist is able to assess and interpret eating, drinking and swallowing difficulties. They will then evaluate and implement a plan of care which may include strategies, education and support for both the patient and their family.
Occupational therapist will look at the patient’s motor skills, assess and evaluate ways in which these can be improved to enhance their ability for independent feeding and drinking using adapted equipment.
Physiotherapist will recommend and advise on exercises to help strengthen arms and head control.
Nurse ensures an individualised nutritional care plan is in place as part of the N in the aSSKINg bundle, and should the patient/resident need feeding, ensures this is included within the care plan. The Nurse will also monitor patient food and fluid or enteral feed intake. They will notify and discuss the patient/resident with the doctor and dietician if nutritional intake decreases, they stop eating and drinking altogether, or, they start losing weight or vice versa. Nurses will also monitor and assess a patient/resident’s mouth and provide an oral care plan.
Health Care Assistant works alongside nurses, and assists with handing out meals and ensuring patients that require feeding are supported or fed. They will also highlight any concerns with swallow or food/fluid refusal which are handed back to the Nurse.
In summary, nutritional assessment can be complex and time consuming in consideration of each person’s needs. There is not a ‘one size fits all’ approach. We need to ensure that each patient or resident’s nutritional status is assessed on admission, they are referred accordingly to the MDT, and plan of care is implemented and regularly reviewed.
Consideration of a patient or resident’s nutritional needs is part of the aSSKINg care bundle (NHS Improvement, 2018). Using the aSSKINg care bundle when planning for those in our care ensures that all the essential elements of pressure ulcer prevention and management are included.
Allied Health Professionals (2012) QIPP and ONS Toolkit. Available at: https:// bit.ly/2XcXiMB(accessed 18.02.2020)
British dietetic association (2018) Pressure ulcers (pressure sores) and diet: Food Fact Sheet, Available at: Pressure ulcers (pressure sores) and diet | British Dietetic Association (BDA) (Accessed online: 25.02.2022).
BAPEN (2011) Available at: Malnutrition Universal Screening Tool (bapen.org.uk), Accessed (25.02.2022)
Beldon, P. (2010) ‘The Skin The Body’s defence mechanism’, Wound essentials, 5, pp-112-114.
Bold, J.(2020) ‘Supporting evidenced-based practice in nutrition and hydration’ Wounds UK, 16(2), pp. 22-28.
European Pressure Ulcer Advisory Panel et al (2019) Prevention and Treatment of Pressure Ulcers /Injuries: Clinical Practice Guideline.
Fletcher, J. (2020) ‘Pressure ulcer education 7: supporting nutrition and hydration, Nursing Times [online]; 116: 4, 46-48.
NHS Improvement (2018) Pressure Ulcers: Revised Definition and Measurement. NHS Improvement.
Ousey K, Cutting KF, Rogers AA, Rippon MG. The importance of hydration in wound healing: reinvigorating the clinical perspective. J Wound Care. 2016 Mar;25(3):122, 124-30. doi: 10.12968/jowc.2016.25.3.122. PMID: 26947692. Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. J Clin Med. 2019;8(7):1065. Published 2019 Jul 20. doi:10.3390/jcm8071065