The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 25: Prevention of Skin BreakdownTable 25-2: Skin Care for People with HIVIntervention26 picas• Minimize shower or bath time; providehumidifiers• Avoid hot water• Use gentle cleansers (Dove, Cetaphil,Eucerin, Neutrogena); avoid deodorant soap• Minimize friction during cleansing anddrying (avoid washcloth, pat skin dry)• Apply water-soluble lotion and emollientafter bath while the skin is still damp; applyagain at bedtime (Aquaphor ointment,Aveeno lotion, Eucerin cream or lotion,Moisturel cream or lotion)• If above lotions are ineffective, use lacticacid, urea, or sodium lactate moisturizers(Amlactin 12%, Lac-Hydrin 10%)• Refrigerate topical creams and ointments• Encourage fluid intake, avoid or discouragealcohol and caffeine• Avoid restrictive or nonabsorbent clothing• Keep fingernails short and smooth or wearcotton gloves• Wash hands frequently• Use fragrance-free products vs.unscented agents• Avoid lanolin-based creams or ointmentsRationale• Prevents drying of skin• Prevents vasodilation, which exacerbatesitching• Prevents removal of skin’s natural moisture;deodorant soap dehydrates skin• Prevents mechanical irritation• Adds or helps to retain moisture• Adds or helps to retain moisture• Refrigeration produces cooling sensation,which has an antipruritic effect 1• Maintains hydration of skin 1• Guards against mechanical stimulation• Guards against breaking the skin whilescratching• Prevents contamination of open areas• Unscented products may contain fragrancemaskingwhich elicit allergic responses in50% of patients 1• Produces a high rate of allergic responseOnce assessment is completed and risk is determined, implementing skin care guidelines andteaching caregivers is an essential component of the overall nursing care plan.DETERMINING RISK OF BREAKDOWN■ To determine risk of skin breakdown, a thorough nursing history should be obtained thatincludes a history of any dermatologic conditions. A validated, reliable risk assessment toolshould be used to determine risk of breakdown based on mobility, nutrition, sensory perception,degree to which skin is exposed to moisture (incontinence, diaphoresis), and external forcessuch as shear and friction in the bedbound individual. Visual inspection of the skin is critical todetermine presence of lesions, ulcers, or rashes. Dry, flaky, and/or itchy skin should also benoted.Full-body skin checks should be an integral part of the initial exam and should be continued ona regular basis for all individuals who are deemed to be at risk, however minimal. Risk assess-506U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 25: Prevention of Skin Breakdownment should be done at regular intervals and any time a change in condition warrants (e.g.,acute episodes requiring hospitalization, a period of immobility no matter how brief, a change inmedication with new onset of side effects, etc.).PRURITIS26 picas■ Perhaps the most common manifestation of HIV-related skin disorders is that of dry and itchyskin. A host of dermatologic as well as systemic illnesses contribute to this condition, and it isessential that these skin disorders be evaluated and diagnosed by appropriate medical personnel.Table 25-2 provides a list of nursing measures that can provide symptomatic relief once theappropriate medical regimen has been instituted.PRESSURE ULCERS■ One of the most common, yet often overlooked threats to skin integrity in the chronically illor immunocompromised patient is that of pressure ulcer or decubitus ulcer development. Pressureulcers are commonly seen as long-term complications of completely immobile patients;however, these ulcers can occur in relatively short periods of time in individuals who are acutelyill. See Color Plates 25-1 through 25-5 for the four stages of pressure ulcers. The definitions ofpressure ulcer staging can be found in Table 25-3.Table 25-3: Stages of Pressure Ulcers DefinedStage IStage IIStage IIIStage IVA nonblanchable area of erythema, which does not resolve after 30 minutes ofpressure relief. In dark-skinned individuals this may present as discoloration of theskin, warmth, edema, induration or hardness. The skin is always intact with astage I pressure ulcer.Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer issuperficial with a pale pink wound bed and serous (never serosanguinous)drainage. May present as an abrasion or blister.Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue.Wound bed is beefy pink but may have some necrotic tissue. There may beundermining of peri-wound skin or tunneling. Drainage may be serosanguinous.Underlying support structures are not visible.Full-thickness tissue loss with extensive destruction, tissue necrosis or damage tomuscle, bone or supporting structures. Support structures are visible (tendon, jointcapsule, bone, fascia, muscle).Pressure ulcers must be staged accurately for documentation, reimbursement, and standard of careissues. Pressure ulcers are never downstaged: a stage IV ulcer does not become a stage II, stage IIdoes not become a stage I, etc. as it heals. It would be classified as a granulating stage IV orepithelializing stage IV or finally a healed stage IV.Pressure ulcers cannot be accurately staged until the deepest viable tissue layer is visible. Ulcerscovered with eschar or necrotic tissue cannot be staged until they are debrided. They can be documentedas “full-thickness pressure ulcer unable to stage secondary to the presence of necrotic tissue.”Several tools are available to health care practitioners that are reliable and easy to use. Thetools, referred to as the Braden scale or the Norton scale, measure functional and cognitivestatus and assign a score that correlates with risk for breakdown. 2 A sample of the Braden scalecan be seen in Table 25-4 with a sample decision tree in Figure 25-1. Guidelines for caregiverteaching on skin care can be found in Table 25-1.XXVU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 507
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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A Clinical Guide to Supportive and
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IIIChapter 3.Assessment of Physical
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Chapter 6.26 picasPulmonary Symptom
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 9.26 picasDermatologic Prob
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Chapter 10.26 picasPsychiatric Prob
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Chapter 11.26 picas Substance Use P
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 18.26 picasLegal and Financ
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Chapter 19.Palliative 26 picas Care
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DRUGS AND THERAPIES INDEXNOTES: Ent
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