Recognizing skin breakdown
Recognizing Skin Breakdown – What is normal and what isn’t?
What Should Skin Look Like?
In recognizing skin breakdown, one of the first clues is changes in the skin’s color due to a decrease in circulation to the area. In lightly pigmented people, the skin normally has a pink color, so it’s easier to see the blood vessels near the skin’s surface. In deeply pigmented people, skin color changes are not as easy to detect. When trying to detect changes, look in fingernail beds, lips, mucous membranes of the mouth, the underside of the arm and hand, and the whites of the eye.
- Poor circulation causes the skin to appear pale, white, ashen, gray, waxy, and translucent like a white candle (think of what skin might look like if it were frozen or abnormally cold).
- If the skin doesn’t have enough oxygen, it appears bluish or gray. That’s called Cyanosis.
- Red skin color happens with carbon monoxide poisoning, high fevers, sunburn, mild thermal burns, or any time the body can’t get rid of its own high levels of heat.
- Liver disease causes a yellow cast to the skin called jaundice.
- Normally skin temperature is warm to the touch. If it feels significantly hot, then the person likely has a fever, sunburn, or hyperthermia.
- Skin is cool in the early stages of shock, plus the person sweats profusely, heat exhaustion occurs, and profound hypothermia and or frostbite occurs.
- The skin is normally dry.
- Wet, moist, or excessively dry and hot skin is abnormal.
The capillary refill test determines the circulatory system’s ability to restore blood. Press your thumb against a fingernail bed firmly until the bed turns white. Release pressure. The nailbed should return to normal in 2 seconds.
What are Signs of Infection?
Infection is different from inflammation, which meaning the area is damaged in some way but not always infected. With infection, you usually see pus, fever, swelling, and pain. (Pus is a thick, yellowish-white or green liquid made of dead white blood cells, bacteria, and tissue debris and often has a foul odor.)
The Type of Drainage Tells You How It’s Healing
Wound drainage is common in many types of wounds (including open wounds) while they are healing. The type of wound drainage you experience can help to know how well the wound is healing. Some types of drainage from wounds also indicate the presence of bacteria and that the wound is infected.
Normal vs. Deviating from the normal, average, or expected; Outside of what is expected or uncharacteristic. Drainage
Wound drainage is also called exudate. Some types of normal wound drainage look like thin clear watery fluid, whereas others may resemble clear blood fluid. It’s common for infected wounds to ooze yellowish or green fluid that may be thin to a thick consistency. Depending on if there is blood in the drainage from an infected wound, it may leak fluid with a cream-coffee appearance. The skin around the wound may be warm to the touch. The wound may appear red and inflamed. If you see red streaks branch out from the wound, that’s a sign that the infection may be spreading to your bloodstream. Infection in your blood is very serious. Contact the doctor immediately to report this development.
If you have to care for a wound, it’s important to know the common types of wound drainage. The color of drainage can help you know if the wound is healing properly or if wound drainage is showing signs of infection.
What are some of the things that Cause Skin Breakdown?
Prolonged, unrelieved pressure to one area, frequently seen around a bony area such as the tailbone, hips, heels, ankles, or elbows, often causes the skin to breakdown.
Decreased Blood Flow
The constant pressure causes damage by decreasing the blood flow to the skin and traumatizing the area. As the traumatized area rubs against the surface it touches (sheets, wheelchair cushion, etc.), the friction starts tearing away surface cells, and tissue is damaged. Other contributing factors often interfere, such as moisture from fecal or urinary incontinence, poor nutrition or hydration, and generally poor health.
Recognizing skin Breakdown – Early stages
Inflammation is usually the first sign of pending trouble. With inflammation, you see redness, heat, swelling, pain, and fever-like infection, but there is no pus. You may also see blisters, wearing away or tears of the skin in the affected area, breaks in the skin, maceration (softening or whiteness) of the skin, swelling, itching, and development of a blue color to the skin.
You want to check to see if the skin is still blanching. The skin is blanching if you push on it, and it gets lighter in color and then returns to its natural color once the pressure is released. That change in color indicates there is still enough blood flow to that area that tissue death is not occurring yet.
Stage 1 Has Started
An area of skin with no open sores but has changed in color, texture, or temperature is considered stage 1 of skin breakdown.
Stages of Skin Breakdown
There are Four Stages to Skin Breakdown and Pressur Ulcer Development
Stage I: Pre-Open Wound
The skin is still attached but appears red and discolored (greyish, ashen). It doesn’t blanch (i.e., lighten) when you push on it. It may also be painful, firm or soft, warm, or cool.
Stage II: Open Wound
The pressure ulcer looks like a shallow, pinkish-red bowl-like wound or may appear to be a blister that hasn’t popped yet or maybe has deflated.
Stage III: Deep Wound
Stage III Ulcers are deeper wounds and look like a crater in appearance, often exposing the fat layer of tissue. The bottom of the wound may have yellow deed tissue called slough present.
Stage IV: Large Scale Tissue Loss
Substantial scare tissue loss has occurred by this point in time. The wound exposes bone, muscle, and tendons. The bottom of the ulcer contains slough, and dark, crusty dead tissue (eschar). The deep damage is extensive and takes a long time to heal.
Types of Wound Drainage
Types of Wound Drainage
- Serosanguineous. Thin watery drainage that has a pink to darker red color.
- Sanguineous. Dark red drainage which is blood and usually appears from deep wounds.
- Serous. The thin watery fluid that is clear and often drains from wounds as they are healing.
- Seropurulent. Thin watery drainage similar to serous but has a milky, coffee-cream color and indicates an infection in the wound.
- Purulent. Milky white drainage that oozes from wounds and is usually an indicator of infection.
- Hemorrhagic. Dark red blood drains from the wound and may come out in spurts because damage occurred to an artery, or the wound is not healing properly.
Recognizing Skin Breakdown Occurred
Recognizing Skin Breakdown When It Happens
Upon recognizing skin breakdown, it’s important to begin immediately to take steps to repair the damage. If you don’t, the destruction of the skin occurs. If your initial efforts are not successful, call your doctor for advice. However, before doing so, collect some specific information to share with him/her.
Get an accurate measurement of the wound.
- Place a tape measure across the middle of the wound and measure from the two greatest distances apart in a straight line. That is the length measurement. Record it in centimeters and inches both.
- Do the same thing across the center from top to bottom to obtain the width measurement–distance from point A to B in a straight line. Record it in centimeters and inches both.
- If much tissue has wasted away, you need to know how deep it is. Take a sterile (or if you don’t have sterile, use the cleanest cotton Q-tip you have and dip it into hydrogen peroxide. Insert it into the wound and mark where the wound’s edge would reach on the stem of the Q-tip. Measure that mark against the ruler.
Describe any drainage that might be present
Color – What color is the drainage?
- The clear yellowish fluid that contains a small amount of blood serum is normal.
- Bright red is usually fresh blood leaking from a blood vessel.
- Clear watery fluid can also look yellowish or straw-like color in appearance is also normal and usually seen in blisters. Sometimes when this shows up, it’s an indication of infection starting.
- Milky white possibly mixed with light brown, yellow, or green indicating infected material. May also have an odor with the pus and be painful.
Amount – Usually, the amount of drainage is determined by what appears on the dressing. See below the description of drainage amounts.
- Lack of drainage – nothing on the bandage (for a new open wound, that’s not good because the wound needs moisture to heal)
- Scant drainage – no fluid on dressing, but the wound is moist.
- Minimal drainage – fluid covers up to 25% (1/4) of the dressing.
- Moderate drainage – The dressing is wet and at least 75% covered in drainage.
- Heavy drainage – More than 75% of the dressing is wet. If that much drainage is occurring, then the wound may be having trouble healing.
YouTube Video Resources
Published on Mar 7, 2018 by RegisteredNurseRN. This video provides education on pressure injuries (formerly called pressure ulcers) to include stages, prevention, nursing interventions, and common pressure ulcer sites. Stage 1, 2, 3, 4 pressure injuries along with unstageable pressure injuries and deep-tissue injuries are reviewed.