Journal of Community Nursing

JCN supplement

2015 Vol 29 No 5

DEMENTIA

moistened non-woven swab,

applied for 5–10 minutes to

rehydrate the area

consider using wound closure

strips to secure large skin

flaps. Sutures and staples are

not recommended due to the

fragility of the skin

apply a skin barrier product

as appropriate to protect the

surrounding skin.

Apply the dressing

after securing the flap, select

a suitable dressing such as a

silicone foam and apply without

tension, ensuring a 2cm overlap

around the wound. A foam

dressing with a film can be

successful as it can be more

difficult to remove for patients

with dementia

the dressing should be

appropriate for the category

of the skin tear, wound

characteristics, exudate volume

and periwound condition

(LeBlanc et al, 2011)

traditional adhesive strips should

be avoided (Meuleneire, 2003).

Consider gentle micro-adherent

wound closure products where

the skin is very fragile

if possible, leave the dressing in

place for up to five days to avoid

disturbance of the skin flap

mark the dressing with an

arrow to indicate the direction

of removal as per local policy.

Use this arrow for direction of

removal and record in the notes.

Review and reassess

at each dressing change (i.e.

every 3–7 days), gently lift and

remove the dressing, working

away from the attached skin

flap. Consider using saline soaks

or silicone-based adhesive

removers to minimise trauma to

relieving devices and positioning

techniques

Encouraging the patient to wear

appropriate footwear and clothing

to reduce the risk of injury

Using clear signs to

assist dementia patients

with orientation

Considering the use of pressure

mats or other aids to alert staff

when patients are on the move.

CARE OF THE SKIN AND

PERIWOUND AREA

Protection is vital in maintaining skin

integrity. Keep the skin well hydrated

by maintaining nutritional intake and

fluid balance. Patients with dry skin

on their arms and legs will benefit

from a twice-daily application of an

appropriate pH-friendly moisturising

cream (Hanson et al, 2005). It is

important to:

Avoid the use of soap, which can

dry the skin. Use pH-friendly soap

and cleansing solutions

Apply emollients to moisturise

and rehydrate dry skin

Reduce moisture from

incontinence or other sources

Use a barrier film or cream to

protect vulnerable skin

Where adhesive products are

used, consider a silicone-based

adhesive remover to minimise

trauma to fragile skin

Protect fragile skin by covering

with tubular or roller bandages,

long-sleeved clothing etc.

PRESSURE ULCERS

Pressure ulcers can be defined as

‘areas of localised damage to the

skin and underlying tissue caused

by pressure or shear and/or a

combination of these’ (NPUAP, 2014).

Age increases the risk of

developing pressure ulcers and

this risk is further increased by the

diagnosis of dementia. This is due

the periwound skin (Meuleneire,

2003; Beldon, 2006)

when removing the dressing,

take care not to disturb the

skin flap

monitor for changes in the

wound. Where the skin or flap

is pale and dusky/darkened, it

is important to reassess within

24–48 hours

observe the wound for signs of

infection, including increased

pain and exudate, redness, heat,

oedema and malodour

use digital photography where

possible to document the wound

adopt preventative skin care to

avoid further skin tears.

How to prevent skin tears

Most skin tears occur during routine

patient care activities such as lifting,

washing or moving patients (Everett

and Powell, 1994). Key strategies

include creating a safe environment by:

Ensuring adequate lighting

and positioning small furniture

(night table, chairs etc) to avoid

unnecessary bumps or knocks.

Remove rugs and unnecessary

furniture

Upholstering sharp borders of

furniture or bed surroundings

with padding and soft material

Using appropriate aids when

transferring patients and adopting

good manual-handling techniques

according to local protocols, e.g.

slide sheets

Never using a bed sheet to

move the patient as this can

contribute to damage by causing

a ‘dragging’ effect on the skin

(Beldon, 2006). Always use a

lifting device

Where possible reducing or

eliminating pressure, shear

and friction using pressure-

Table 1:

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Category 1a

Category 1b

Category 2a

Category 2b

Category 3

A skin tear where

the edges can be

realigned to the normal

anatomical position

(without undue

stretching) and the skin

or flap colour is not

pale, dusky

or darkened

A skin tear

where the edges

can be realigned

to the normal

anatomical

position (without

undue stretching)

and the skin or

flap colour is pale,

dusky or darkened

A skin tear

where the

edges cannot be

realigned to the

normal anatomical

position and the

skin or flap colour

is not pale, dusky

or darkened

A skin tear

where the

edges cannot

be realigned

to the normal

anatomical

position and

the skin or

flap colour is

pale, dusky or

darkened

A skin

tear where

the skin flap

is completely

absent

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Neuron death is the main

cause of dementia and is

often related to malfunctions

in the way that neurons

‘communicate’