What it means
A loss of the skin's normal, unbroken surface. It happens when skin is pressed for too long (especially over bones), rubbed or pulled, or kept wet by urine, stool or sweat. Clients who cannot move on their own, eat poorly, are incontinent, or have poor circulation are most at risk. Once skin opens, germs can get in.
For the nurse
Check skin at least every shift, using a risk tool such as the Braden Scale. Reposition clients who cannot move themselves at least every 2 hours, keep skin clean and dry, and support good nutrition.
In a chart
"Early skin breakdown on the sacrum: non-blanchable redness, skin intact; turning schedule increased."
Related terms
incontinence
Loss of control over the bladder or bowel, so urine or stool leaks out without the person meaning it to.
ulcer
An open sore where the skin or the lining of an organ has broken down.
integumentary
Relating to the skin and the parts that grow from it, such as hair, nails and skin glands.
immobility
Being unable to move about freely, such as being kept in bed or a chair.