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

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