NHS Continuing Care – The Domains – Skin

18 Oct

shutterstock_50068234 (27) - Copy - CopyDomain 8 – Skin

These physical health domains tend to be easier to score – if that is possible!!

Skin works well in general, it’s role in a very broad sense is to keep everything in and to much more importantly to keep out infection.  If skin is there and there are no holes, it tends to do its job.  So even if someone’s skin is very fragile and bruises easily, although it may not be pretty, it is working.

There can be minor issues regarding dry, fragile skin that can break easily.  I remember a few years ago now having a minor operation and I had a needle inserted into the back of my hand, which was held on with a big plaster.  When the nurse can to remove the plaster she was very careful and I suggested that she just rip it off.  She said that she didn’t do that as an older persons skin might come off with the plaster.  That was before I became an elderly client solicitor and I was surprised at the idea.  So skin works as long as its in place and things go wrong when it get holes.

Low level of need would be skin that easily bruises or tears.  Then there is a risk of pressure damage and low would be a relatively low level of risk of pressure damage, someone mobile, possibly someone mobile but incontinent.  Then there are the minor skin issues that require some creaming, but only daily as a maximum, not more frequently than that. Eczema and/or psoriasis that is under control would be considered a low need.

Moderate is about skin that heals or is at higher risk of pressure damage.  Healing skin is skin that tears, but is healing, if its healing, then its keeping out infection, so minor cuts or minor pressure damage that is healing.  Moderate would also cover eczema and psoriasis that is not so under control and that needs treatment and/or someone to check it multiple times a day.

As always the DST is about risk, pressure damage is a risk factor and therefore skin at risk of pressure damage, so at risk of skin not being able to do its job is a risk.  Therefore skin at high risk of pressure damage, even though its intact would be a moderate score.  Risk of pressure damage is scored numerically under a system called “waterlow”.  Under 10 is not considered a risk, 10-15 moderate risk, 15-20 high risk and 20+ very high risk.  There will almost always be a waterlow score, so check that.  In general though, someone relatively immobile and incontinent would have a high risk of pressure damage and would score moderate.  If that was the case, they are likely to be on a turning rota and would be re-positioned every few hours.

It is also worthwhile finding out what cushions and mattresses are in place.  Someone at risk of pressure damage may well have special cushions to sit on and/or a special mattress or mattress cover.

After moderate, it means that skin is no longer intact and therefore infection can set it.  If the infection is not controlled it is possible to get septicaemia, which can prove fatal.  High needs is about pressure damage not responding to treatment or very deep pressure damage which is responding, but it would take a while to heal.  I’ve scored high when someone has a series of pressure sores that although each end up healing, as soon as that happens another one breaks out, which means that overall, the person is never free of pressure damage.  This argument is not always accepted, but usually is.

Severe needs is about really big problems with skin.  It about pressure damage that’s bone deep, it’s about skin that is not healing or there are multiple wounds.  It is rare that this is scored, as these kinds of problems don’t arise that often, but it can happen.  This would require very specialist dressing and specialist monitoring.

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