A Clinical Guide to Supportive and Palliative Care for HIV/AIDS
Chapter 25. Prevention of Skin Breakdown
Maintenance of skin integrity in people with HIV poses a number of challenges to health care practitioners and caregivers. Because of the nature of HIV, it can be difficult, if not impossible, to heal open wounds or ulcers once they appear. It is for this reason that clinicians must work closely with patients and their caregivers in instructing them in principles of skin care. The clinician should teach symptomatic relief of some of the more common skin problems and also address basic assessment of skin so that the caregiver can report problems as soon as they occur. Vigilant caregivers in the home are the patient's best defense against the long-term complications of pressure or decubitus ulcer formation. (See Tables 25-1, PDF and 25-2, PDF)
While assessing and treating skin disorders is clinically important throughout the course of HIV infection, the challenges of maintaining skin integrity are greatest for patients with advanced disease. Prevention and treatment of late-stage dermatologic complications is a critical aspect of comprehensive palliative care for patients with HIV disease, and can also be an important means of involvement and empowerment for family caregivers in the care of their loved ones with AIDS.
Because there are many dermatologic conditions associated with HIV it is essential that the patient have a thorough medical evaluation for diagnosis and treatment of these skin problems once they occur (see Chapter 9: Dermatologic Problems). Equally important is the nursing assessment of the individual to determine not only the presence of any open areas but to determine the patient's risk for skin breakdown at any time during the continuum of the illness.
Once assessment is completed and risk is determined, implementing skin care guidelines and teaching caregivers is an essential component of the overall nursing care plan.
Determining Risk of Breakdown
To determine risk of skin breakdown, a thorough nursing history should be obtained that includes a history of any dermatologic conditions. A validated, reliable risk assessment tool should be used to determine risk of breakdown based on mobility, nutrition, sensory perception, degree to which skin is exposed to moisture (incontinence, diaphoresis), and external forces such as shear and friction in the bedbound individual. Visual inspection of the skin is critical to determine presence of lesions, ulcers, or rashes. Dry, flaky, and/or itchy skin should also be noted.
Full-body skin checks should be an integral part of the initial exam and should be continued on a regular basis for all individuals who are deemed to be at risk, however minimal. Risk assessment 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 in medication with new onset of side effects, etc.).
Perhaps the most common manifestation of HIV-related skin disorders is that of dry and itchy skin. A host of dermatologic as well as systemic illnesses contribute to this condition, and it is essential that these skin disorders be evaluated and diagnosed by appropriate medical personnel. Table 25-2 (PDF) provides a list of nursing measures that can provide symptomatic relief once the appropriate medical regimen has been instituted.
One of the most common, yet often overlooked threats to skin integrity in the chronically ill or immunocompromised patient is that of pressure ulcer or decubitus ulcer development. Pressure ulcers 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 acutely ill. See Color Plates 25-1 through 25-5 for the four stages of pressure ulcers. The definitions of pressure ulcer staging can be found in Table 25-3 (PDF).
Several tools are available to health care practitioners that are reliable and easy to use. The tools, referred to as the Braden scale or the Norton scale, measure functional and cognitive status and assign a score that correlates with risk for breakdown.2 A sample of the Braden scale can be seen in Table 25-4 (PDF) with a sample decision tree in Figure 25-1 (PDF). Guidelines for caregiver teaching on skin care can be found in Table 25-1 (PDF).
Although pressure is often overlooked as a causative factor in skin breakdown, the reverse can sometimes be true. That is, ulcers may be assigned a diagnosis of pressure ulcers when in fact pressure may not be the root cause.
One commonly misdiagnosed condition is herpes simplex ulcer infections, especially perianal herpes. Because of their location these ulcers can be mistaken for stage II or III pressure ulcers. Although continued unrelieved pressure to the lesions will certainly lead to wound deterioration regardless of etiology, treatment of herpes must include pharmaceutical management. Because medication is critical to healing it is of paramount importance to quickly recognize and treat herpes. (See Chapter 9: Dermatologic Problems.) To distinguish perianal herpes from pressure ulcers, clinicians should remember that with herpes, there is generally more than one lesion and these lesions are usually distributed bilaterally. Also, herpes ulcers are more painful than pressure ulcers of similar depth, and aggressive pain management is often required. (See Chapter 4: Pain.) Finally, herpes ulcers will not respond to conventional treatment for pressure ulcers.
Skin care for people with HIV is a critical component of palliative care. Because of the many factors contributing to these sometimes debilitating skin disorders it is essential to approach skin care as a team. Physicians, nurses, patients, and caregivers must all work together to provide medical management as well as symptomatic relief.