The first line of defense is the intact skin. With aging, there is a loss of subcutaneous tissue and thinning of the skin takes place. If the resident is immobilized, there maybe development of pressure sores. Skin care programs should address bathing, trauma, and skin maceration. Each nursing home should develop a skin assessment program and observation of the possible development of pressure sores.

Pressure sores (often called decubitus ulcers) by definition are soft tissue lesions where cell death has occurred because of decrease in blood supply. The lesions that develop vary in severity from simple inflammation to ulceration of the skin layers that may extend through muscle and reach the bone. These lesions may or may not be infected regardless how deep the ulceration may occur. If there is purulent drainage (pus formation), then the ulcers are considered infected.

A study of 20,000 residents in 1997 over 60 years of age in 51 nursing homes showed an overall prevalence at time of admission to be 17%. This percentage decreased after one year to 10% and to 8% after two years.

1. Stage 1 - Non-blanchable erythema with no breaks in the skin (intact)
2. Stage II - Partial thickness skin loss involving epidermidis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
3. Stage III - Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying facia. The ulcer presents clinically as a deep crater with or without underming of adjacent tissue.
4. Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structure.

1. pressure
2. poor nutrition
3. wetness/dampness
4. improper positioning
5. poor hygiene
6. shearing
7. friction
8. use of restraints
9. casts
10. braces

1. incontinence
2. decreased mobility
3. impaired circulation
4. fractures
5. poor nutritional status
6. diabetes
7. stroke
8. Alzheimer’s
9. abnormal body weight
10. depression
11. confusion
12. dementia

4) Causative Organisms

Most often the ulcers that are produced may become contaminated with the resident’s own flora such as Escherichia coli and Proteus mirabilis and Enterococcus and develop into an infected lesion. However, it is not unusual for these ulcers to become infected with Staphylococcus aureus or Streptococcus pyogenes which may lead to severe ulceration and blood invasion.

The best method of prevention is to prevent the ulcer itself. Nursing measures for prevention and treatment of pressure sores is risk assessment of the resident which includes but not limited to, proper positioning/turning on a specific schedule, providing adequate nutrition, establishing proper hygiene, clean dressing, proper medications and debridement when necessary.

Many types of microorganisms may be transmitted from the hands of health care personnel to the resident in a long-term care facility. In order to encourage healthcare personnel in a long-term care setting to wash their hands appropriately, they must understand that the microorganisms found on residents are different and could be more dangerous (resistant to common antibiotics) than the ones found in their home. Federal regulations for nursing homes state that each facility must require their staff to wash their hands after each direct resident contact.

Education on handwashing and its importance on preventing infection to residents is an ongoing effort. It is an important part of the orientation process for all personnel and must be continued throughout their employment.

Personnel must be able to handle, store and process linens in a manner to prevent infections. The proper processing of linens with the use of detergents, sours, enzymes and fabric softeners will prevent skin irritations and breakdown thus providing the resident in a long term care facility a lesser chance to develop an infection (sepsis) and possible hospitalization.

Malnutrition has an impact on a human’s immune system and wound healing. In order for a nursing home to meet the nutritional needs of a resident, the food must be enticing and edible taking into account the resident’s ethnic background. All meals should be served to the residents in a quite setting with good temperature controls and lighting.

All residents should be monitored for any protein-caloric undernutrition. Any sign of a decline in the resident’s nutritional status should be immediately noted and corrected as soon as possible.

 Alzheimer’s disease

The most common form of dementia among older persons is Alzheimer’s disease (AD) that involves parts of the brain that controls thought, memory and language. Although doctors are learning more about this complication, at the present time there is no known cause or cure for this disease.

AD begins slowly and at first, the only symptom is mild forgetfulness such as remembering recent events or names of familiar people or things. As symptoms progress, they forget how to brush their teeth or comb their hair, think clearly, have problems with their speech, reading or writing. As the disease progresses to severe AD, incontinence develops, the patient loses weight, the skin becomes thin and tears. The patient needs total assistance for all activities and daily living.

Skin integrity of the residents is preserved by adequate nutrition, hydration and good nursing care that includes daily inspection, compliance with proper body alignment and positioning and maintenance of maximum mobility.

Skin must be inspected daily for potential breakdown, repositioning the resident every two hours, keeping the resident’s skin clean and dry, and finally keeping the skin well lubricated. The physician and the infection control nurse should be consulted for any special skin care treatment and medications.

Handwashing is the most common and effective method that can be performed to prevent the transmission of organisms to residents or to the healthcare care workers themselves.

There are two major groups of microorganisms found on the skin: organisms that normally reside on the skin (resident flora) and organisms that can be obtained from the environment or from patients/residents (transient flora).

Handwashing prevents transmission of transient flora to patients, food and articles that are handled which may have direct contact with patients. Hand antiseptic agents are designed to eliminate most transient flora by their mechanical detergent effect and to exert an additional antimicrobial activity on remaining flora.

The most frequently reported reason given by healthcare workers associated with poor compliance of handwashing is the inconvenient location of sinks. Facilities must provide the healthcare worker the opportunity to wash their hands. The added convenience of pocket or neck holders of bottles containing alcohol sanitizers would be one example of such a convenience.

Because of the drying effect of frequent handwashing, healthcare personnel may be reluctant to wash their hands as often as required by the facility. The use of emollients (chemical agents that help soften the skin) in hand sanitizers has created a better compliance of use by healthcare workers. Personal hand lotions supplied by the facility and only used on premise have also lessened the chances for skin irritation.

Because of the reluctance of healthcare workers to wash their hands and the frustration of facilities because of their lack of success to promote consistent handwashing protocols, perhaps an educational forum can be developed to family members on admission to participate in a program to encourage handwashing in personnel who provide care for them.