This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the first three descriptors in the Skin domain, to help you assess your or your relative’s “level of need” in this important domain.

Don’t miss parts one, two, three, four, five and six of this series:

Get Help Breaking Down The Decision Support Tool: An Overview

Get Help Breaking Down the Decision Support Tool: Breathing Part 1

Get Help Breaking Down the Decision Support Tool: Breathing Part 2

Get Help Breaking Down the Decision Support Tool: Nutrition Part 1

Get Help Breaking Down the Decision Support Tool: Nutrition Part 2

Get Help Breaking Down the Decision Support Tool: Continence

Following the 2018 revisions of the DST, Skin moved “up” from number 8 to number 4. As in the 2012 version, it still follows the Continence domain, highlighting the common interaction between these domains: incontinence greatly increases the risk of tissue breakdown as the skin is often moist. However, unlike the 2012 version, in the updated 2018 DST the Skin domain is followed by Mobility, emphasising the significant impact of immobility on skin integrity. Any interrelation between domains (complexity), and its potential impact on the delivery of care (intensity/unpredictability), should be considered in the analysis of the four Key Characteristics.

The assessed levels of need in the Skin domain range from ‘No Needs’ to ‘Severe’. There is no descriptor for a ‘Priority’ level of need in this domain, indicating that an issue with skin integrity is unlikely to present an immediate risk to life, in and of itself.  That being said, the complications arising from pressure damage or other skin wounds can certainly be life threatening and swift, skilled treatment is essential. The vast majority of people being assessed for CHC will fall into the descriptors for a ‘Low’ or ‘Moderate’ level of need. The ‘High’ and ‘Severe’ levels of need are reserved for those suffering from extensive or non-healing wounds, which will usually require specialist treatment by the Tissue Viability Nurse (TVN).

*IMPORTANT – When looking at skin integrity and its likelihood of breaking down, care providers use the “Waterlow” risk assessment. This brings together a number of risk factors – age, mobility, continence, BMI, prescribed medications – to give an overall score, ranging from “no risk” to “very high risk” – the higher the score, the greater the risk.

The following clinical factors are relevant to the assessment of no needs, low and moderate level needs in this domain:

• What is the condition of the person’s skin – dry, paper, friable, healthy?
• Is the person well-nourished and hydrated? What is their BMI?
• What is the person’s “Waterlow*” score?
• Does the person have any existing skin conditions – eczema, psoriasis, pemphigoid?
• Do they require the application of prescribed creams?
• How frequently are these applied, once daily or more frequently?
• Is the person continent of urine and faeces?
• Do they use incontinence products (e.g. pads)?
• Is the person independently mobile?
• Are they able to alter their position in bed and/or chair?
• Do they require prompts, assistance and/or encouragement to change their position regularly?
• Is any pressure-relieving equipment in use – i.e. cushion, mattress, heel protectors?
• Is the person’s skin intact (not broken)?
• What is the extent of any existing skin damage – i.e. how deep are the wounds**?
• What treatment regime is required and who delivers it?
• Is the treatment effective – i.e. are the wounds responding/improving?

**NOTE – Wounds are “graded” from 1-4 using a wound chart. Grade1 describes very superficial damage to the top layer of skin (epidermis), such as reddening or blanching. Grade 4 describes extensive damage to all three layers of the skin (epidermis, dermis, hypodermis). Extensive skin damage puts the underlying bones and joints at risk.

IMPORTANT – The DST provides the following guidance to the MDT when assessing needs in this domain: Evidence of wounds should derive from a wound assessment chart or tissue viability assessment completed by an appropriate professional. Here, a skin condition is taken to mean any condition which affects or has the potential to affect the integrity of the skin.

This underlines the importance of having clear, dated evidence to confirm the extent of any risks to skin integrity, their underlying causes and the treatment required. Any skin damage should be clearly recorded on a body map and all wounds should be measured and graded. All treatments and interventions should be recorded in detail, including whether the wound is responding to treatment. This is particularly important for those receiving care at home, where record keeping is often less robust and wounds are treated by District Nursing teams.

Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for ‘No Needs’, ‘Low’ and ‘Moderate’ levels of need. For each descriptor, we provide a case study to give you a better understanding of how the levels of need might be applied at your or your relative’s assessment.

NO NEEDS

No risk of pressure damage or skin condition.

Key Factors Healthy, intact skin No or low risk to skin integrity Person is independently mobile and fully continent

CASE STUDY – NO NEEDS

Mrs. X’s skin is healthy and intact. She is well nourished and remains fully continent of urine and faeces.

Mrs. X is independently mobile and is able to change her position in bed and chair throughout the day and night.

Mrs. X is not prescribed any emollients or creams, although she does like to use Aveeno after her bath to keep her skin soft which she applies this herself.

Mrs. X presents with ‘No Needs’ as she has no risk of pressure damage or skin condition.

LOW

Risk of skin breakdown which requires preventative intervention once a day or less than daily without which skin integrity would break down. OR Evidence of pressure damage and/or pressure ulcer(s) either with ‘discolouration of intact skin’ or a minor wound(s). OR A skin condition that requires monitoring or reassessment less than daily and that is responding to treatment or does not currently require treatment.

Key Factors Moderate risk of skin breakdown Minor, superficial wounds (grade 1) Intervention required daily, or less frequently

CASE STUDY 1 – LOW

Summary of Needs:

Suffers with dry skin

Doubly incontinent

Waterlow = 17 (high risk of skin breakdown)

Care Plans:

Skin intact but Waterlow has increased and skin integrity more vulnerable since becoming doubly incontinent

More incontinent now and wears pads

Dry skin to hands, not to body

Spends most of her time in chair. Able to reposition.

Nurse Assessor’s comments:

Mrs. X is doubly incontinent and has impaired mobility and awareness of her various needs. She requires monitoring of her skin condition and is assessed as being at high risk of skin breakdown (Waterlow score of 17). Her care plans on admission and thereafter indicate that her skin has remained intact and baby lotion is applied once a day for moisturisation which has since been changed to Zerobase. Mrs. X is noted to be able to reposition herself for pressure relief, both when seated and lying down. She alters her position spontaneously throughout the day and night and does not require prompts or encouragement to do so.

Mrs. X presents with a ‘Low’ level of need as she is at risk of skin breakdown which requires preventative intervention once a day or less than daily without which skin integrity would break down.

CASE STUDY 2 – LOW

Mrs. X’s skin is healthy and intact. She does not require the application of any creams and does not suffer from any skin conditions.

Mrs. X has been unwell in the past week with a chest infection and she currently has a grade 1 pressure sore on her right ankle after a period of bed rest, measuring 1cm x 1cm. A small dressing has been applied for protection and Mrs. X’s leg is elevated on a cushion to relieve pressure. Care records indicate that the wound is responding well to treatment.

Mrs. X presents with a ‘Low’ level of need as she has evidence of pressure damage and/or pressure ulcer(s) either with ‘discolouration of intact skin’ or a minor wound(s).

CASE STUDY 3 – LOW

Mrs. X has a recent history of cellulitis, and her skin remains vulnerable.

Care Home Records:

• 02/06/2021: Request Matron visit due to Mrs. X’s legs being swollen, red and angry. Matron checked over, done observation, has cellulitis. Antibiotics prescribed. Also, fluids restricted to 1500mls. Matron also going to arrange bloods. To observe, do NEWS score tomorrow. If becomes redder or tracks up legs to ring 111 for medical advice. If becomes unwell or flu like symptoms, high temp, will need to go to hospital.
• 14/06/2021: Matron visited to review legs. Redness now reduced, to complete antibiotics. If new concerns to call back.
• 27/06/2021: Leg healed, no signs of infection or redness.

Additional information provided by senior carer: Mrs. X’s skin is currently intact. She no longer has cellulitis. Her skin is monitored for signs of infection and a body map is completed each week.

Mr. X presents with a ‘Low’ level of need as he has a skin condition that requires monitoring or reassessment less than daily and that is responding to treatment or does not currently require treatment.

MODERATE

Risk of skin breakdown which requires preventative intervention several times each day without which skin integrity would break down. OR Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment. OR An identified skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.

Key Factors Incontinence of urine and/or faeces Restricted mobility or complete immobility (bed or chair bound) High Waterlow score – at significant risk of skin breakdown Requires prompts, encouragement, partial or full assistance to alter position Pressure relieving equipment in use Prescribed creams applied several times each day Grade 2 wound(s), responding to treatment

CASE STUDY 1 – MODERATE

No skin problems.

No history of skin conditions.

Doubly incontinent.

Proshield as cleanser and has barrier cream applied after each personal care intervention.

Airflow mattress.

Previously (long time ago) had some redness to sacrum but no longer present.

No pressure ulcers.

Skin condition good.

Emollient once a day after shower/strip wash – all over body.

Care provider records:

SBAR report dated 10/10/2019

Waterlow risk assessment score = 24 (very high risk)

Waterlow risk assessments:

11/06/2018: 23

30/10/2018: 23

18/02/2019: 24

11/06/2019: 24

10/10/2019: 24

Nurse Assessor’s comments:

Mrs X is doubly incontinent, immobile and severely cognitively impaired. She is dependent on the full assistance of 2 members of staff to assist her to reposition regularly and to check and change continence pads and apply barrier creams to help reduce the risk of skin breakdown. She is assessed to be at very high risk of skin breakdown and is nursed on a pressure relieving air mattress when in bed, and has a pressure relieving cushion for use when sitting out in her wheelchair or armchair. Her position is changed every four hours by staff in accordance with her care plan.

There is no evidence of any open wounds, pressure areas, or skin conditions which require any specific interventions from staff greater than basic care to prevent skin breakdown.

Mrs. X presents with a ‘Moderate’ level of need as she is at risk of skin breakdown which requires preventative intervention several times each day without which skin integrity would break down.

CASE STUDY 2 – MODERATE

Family’s Comments:

Grovers disease. Needs twice daily emollients for dry skin condition

Steroids thin skin. Skin tears almost constantly.

Base of spine very sore requires barrier cream twice day.

MDT Notes:

Has skin condition and needs moisturising twice a day and has thin and fragile skin due to steroid treatment.

Weight loss impacted on her sacrum.

Skin is fragile and thin and dry

Emollient (Diprobase)

On admission had scabbed areas.

Skin is very vulnerable.

Prescribed Epaxiban which can also lead to bruising and requires monitoring.

Prescribed barrier cream, applied after each personal care intervention.

Very high risk of pressure sores. Repositioned 3-hourly

Skin checked twice daily – carers report any issues.

Nursed on pressure relieving air mattress and pressure cushion.

Currently has 2cm x 1cm G2 sore at base of spine, dressed with Inadine and Mepore, responding to treatment.

History of numerous superficial wounds.

Care home records:

01/02/2021: Daily records – Dacktocort cream applied on left upper thigh and groin

03/02/2021: Daily records – Blister on his left upper thigh popped out and put a Biatain dressing on that and done the wound care plan

04/02/2021: Daily records – X’s bottom is sore lbf applied arms sore and slightly bleeding nurse advised X is very unsettled

05/02/2021:  X is very confused this morning during personal care noticed bruise on her left foot nurse informed X’s blood blister on leg had popped cleaned and cream applied pad left open

07/02/2021: Daily records – she remains confused at times but was communicating well. Right arm wound checked and assessed.

15/02/2021: Daily records – Assessed skin flap appeared clean and healthy. Granulation apparent. Cleaned and refreshed as per care plan. No concerns raised. Left hand skin flap assessed.

22/02/2021: Daily records – Dressing came off those morning on left forearm, no sign of infection, Biatain silicone applied.

24/02/2021: Daily records – 5/5 cm wound on left forearm is healed no dressing required

MDT’s Comments:

Mrs. X has a diagnosis of Groves disease, which has resulted in her skin being very fragile and dry, and she is prone to skin tears due to use of steroids. She is prescribed a blood thinning medication which increases her risk of bruising.  She is prescribed emollient creams which are applied twice daily and, due to double incontinence, requires the use of barrier cream to reduce the risk of excoriation, which is applied at each personal care intervention.

Mrs. X is at high risk of skin breakdown due to immobility, poor nutritional status and double incontinence and is nursed on a pressure relieving air mattress and is repositioned 3-hourly with the assistance of 2 members of staff.

Mrs. X has sustained numerous superficial skin tears, bruises and abrasions in the short period of time since admission, some of which have required dressing and regular monitoring from nursing staff. They were noted to have healed quickly and there is no evidence to indicate that the wounds became infected or required any specialist dressings. She is currently receiving treatment for grade 2 pressure damage to her sacrum, which is responding well.

Mrs. X presents with a ‘Moderate’ level of need as she has pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment.

CASE STUDY 3 – MODERATE

Mrs. X suffers from eczema. She has extremely dry, friable skin. She is prescribed Epiderm as an emollient, which is applied twice daily. She is also prescribed hydrocortisone cream to manage exacerbations of her condition.

Mrs. X is inclined to scratch, particularly in hot weather. She needs gentle reminders to try not to scratch, as this increases the risk of infection and deterioration.

Mrs. X’s skin is currently intact and healthy, owing to dedicated efforts by staff to ensure her skin is always well moisturised. Staff check behind her knees and elbows each day, as these are usually the sites that are affected first.

Mrs X presents with a ‘Moderate’ level of need as she has an identified skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.

For further reading around the subject on pressure sores:

The dangers of pressure sores, pressure ulcers and bed sores

Take a holistic approach to improve your chances of getting CHC Funding

Does the NHS Safety Thermometer’s findings impact on your relative’s entitlement to CHC Funded Care?

NICE Guidelines – Pressure ulcers: prevention and management https://www.nice.org.uk/guidance/cg179

We hope this has helped you to understand the first three descriptors in the Skin domain. Don’t miss part 2, coming very soon!

If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today. If you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 Support page.

If there is a particular topic you would like us to cover, we’d love to hear from you! Just send an email via our “Contact Us” page with the subject “blog request” and we’ll do our best to cover your suggested topic.