This is a vital component for pressure ulcer prevention and treatment. The skin is a living functioning complex organ and requires feeding and hydration to function. Vital nutrients help the skin repair and regenerate.
Old age, pressure ulcers and malnutrition may co-exist. Wounds in older people may already be slow to heal as a result of compromised skin integrity, which occurs as part of the normal ageing process. Malnutrition is also more common in older people, and evidence has shown that inadequate nutrition may lead to impaired and prolonged wound healing.
Our National Institute of Clinical Evidence pressure ulcer prevention and management guidelines advising on the importance of using a validated risk assessment screening tool as part of our prevention planning (NICE 2014). Most commonly used is the MUST tool.
As a specialist adviser in tissue viability for the CQC when assisting in care home inspections, regular nutritional screening assessments is a vital component to being compliant in care planning for pressure care prevention. Where care homes have excelled in their nutrition and hydration, the plans are individualised and initial risk assessments and reassessment’s are demonstrated. I always look to see if there is a tissue viability or nutrition champion in house and if the escalation process for concerns is clearly understood and well led. Unfortunately where poor care in nutrition has been evident, too often this has led to serious pressure ulcers, examples such as broken weighing equipment, unable to weigh with staff not able to perform other benchmarks such as the ulna measurement check. Lack of assistance in lunch times, low mood of the residents resulting in poor appetite. This is certainly not a regular occurrence but an emerging theme from serious pressure ulcers in long term care settings.
The basic building blocks of the skin
The skin is made up of only three layers – the outer layer is the epidermis, the second, an inner layer of soft tissue called the dermis, and a base layer called the subcutis. The base layer includes a seam of fat the body uses as a fuel reserve in case of food shortage; this also works as insulation.
The epidermis layer is constantly growing and repairing itself. We shed the dead skin cells and regenerate new ones daily.
When I started as a tissue viability nurse one of my experienced colleagues said to me ‘the skin is just like a plant, without feeding and watering it, the leaves will wither and break’ this has always stayed with me and a phrase I still use in my training sessions. I think we can all too often forget that the skin is a living and breathing vital organ and the largest and most outwardly of the whole body. It requires adequate nutrients and hydration to remain functioning. Skin naturally reflects your body’s internal needs, including what nutrients it requires.
As care providers, recognising when there are changes in the skin, can be a window to something going on internally. Seeing your residents daily, the key person to identify this change is likely to be the care giver, assisting in the personal care of the resident.
Nutrition for skin function
There is no one formula for nutrients to prevent pressure ulcers, rather a balanced diet is preferable. You may have seen the plate model, advocated by the Food standards agency in 2002. This is what dieticians have used as a visual template. However anybody that is nutritionally compromised must have individualised food and fluid care plan, with expert advice from dietician speech and language therapist as indicated by the individual’s needs. Those with a low risk score, a balanced diet may be recommended with regular weights of the residents. If you are concerned that the skin looks less healthy and the weight hasn’t changed, do alert the GP or senior nurse as it may be an indicator of something else going on internally. One of the first signs of changes due to internal and/or external pressure forces along with nutrition compromise may be a category one pressure ulcer. See picture below for an example of a category 1 non-blanching erythema. This is a simple blanching technique to test a red area over a bony prominence to see if it remains red after application of some pressure for three seconds. This will be harder to detect on darker skin tones. If you see this category 1 pressure ulcer simply offload the resident off the affected area and alert somebody immediately. All risk assessments including the MUST nutritional assessment will need to be reviewed at this point. For a quick video on the blanching test; click here.
Dehydration: A common, yet under recognised problem, which can compromise tissue integrity. It is essential to know the signs and symptoms of dehydration and to actively encourage adequate fluid intake.
Malnutrition is potentially reversible. It is paramount that it is identified and addressed early (Elia, 2003).
Don’t forget the aSSKINg bundle, with N standing for Nutrition and Hydration
As a result nutritional assessment is part of our daily practice as nurses and the NICE guidelines recommends using a nutritional screening tool to assess risk of malnutrition. The most common used in the UK being the ‘Malnutrition Universal Screening Tool’ (MUST).
Click here for an online MUST calculator. If your home has digital care plans on iPads etc, why not have a link to this also to allow for MUST assessment support.
The use of prescribed supplements should be an option only after trying to introduce the appropriate foods. As a result of trying to reduce the use of supplements a group of dieticians have put together a great guide called ‘Food First’. Click here for free downloadable leaflets and posters on this. These are great and I used to carry them around with me to give out to patients and their carers.
If your resident is unable to maintain a healthy diet and weight through exploring food options it may be necessary to provide a top up. Supplements must be prescribed and recommended by a dietician who has assessed the resident.
For case studies and ‘Root Cause Analysis’ examples involving nutrition and pressure ulcers check out the NHS improvement page as part of the #stopthepressure campaign here.
A very useful pathway of the NICE guidelines is available online to guide you accessible here.
Elia M, ed (2003) Screening for Malnutrition: A Multidisciplinary Responsibility. Development and Use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults. Malnutrition Advisory Group (MAG), British Association for Parenteral and Enteral Nutrition (BAPEN), Redditch, Worcestershire.
Leaker S. (2013) ’The role of nutrition in preventing pressure ulcers’ Nursing Standard. 28, 7,66-70 accessed online 20th July 2018: https://journals.rcni.com/nursing-standard/the-role-of-nutrition-in-preventing-pressure-ulcers-ns2013.10.28.7.66.e7855.
Pressure ulcers (2014) NICE guideline CG179. Accessed online 20th July 2018. https://www.nice.org.uk/guidance/cg179.