When Skin Breakdown Signals Deterioration: A Cardiac Ward Scenario

You are on a cardiac ward caring for a patient admitted with worsening heart failure.

He has severe lower-limb oedema, becomes breathless with minimal movement and has spent much of the last few weeks sleeping in a chair because lying flat felt uncomfortable. He now needs several staff and size-appropriate equipment for safe repositioning.

During personal care, you notice that the skin more complicated than “a sore bottom”. There may be pressure damage, moisture-associated skin damage and signs of broader deterioration happening at the same time.

What Do You Notice First?

With the patient’s consent, privacy protected and appropriate assistance in place, you complete a skin check with the registered nurse.

You notice:

• non-blanching discolouration over the sacral area
• dark purple discolouration over one heel
• moist, inflamed skin within abdominal and groin folds
• small areas of broken skin where surfaces rub together
• marked oedema and fragile, stretched skin on both lower legs
• pain when the patient is repositioned
• an odour that needs further assessment

The patient looks embarrassed and says, “I haven’t been managing well at home.”

This is a moment for dignity, not judgement.

Pressure Damage and Moisture Damage Are Not the Same

A pressure ulcer is localised damage to the skin or underlying tissue caused by pressure, or pressure combined with shear. It commonly develops over a bony prominence or beneath a medical device.

Moisture-associated skin damage develops when prolonged exposure to moisture disrupts the skin barrier. Sweat, urine, faeces and wound fluid can all contribute.

Skin folds may also develop intertriginous dermatitis where heat, moisture and friction occur together. Fungal or bacterial infection may sometimes develop, but inflamed skin in a fold should not automatically be labelled as fungal without appropriate assessment.

A patient can have both pressure damage and moisture damage. They need to be recognised separately because the care plan may differ.

Look Beyond Redness

Early pressure damage can be harder to recognise in darker skin tones.

Do not rely on redness alone. Compare the area with surrounding skin and look or feel for:

• persistent discolouration
• purple, blue or darker areas
• local warmth or coolness
• firm, hard or boggy tissue
• swelling
• pain or altered sensation
• blistering or skin loss

Do not massage an area of suspected pressure damage.

The Observations Add Another Layer

The patient’s observations are now:

• respiratory rate 26 breaths per minute
• oxygen saturation 93% on room air
• heart rate 108 beats per minute
• blood pressure 158/92 mmHg
• temperature 37.9°C

These findings need to be interpreted against the patient’s prescribed oxygen target, baseline, full National Early Warning Score 2 (NEWS2) assessment and clinical presentation.

The skin findings do not explain every abnormal observation. The patient was admitted with worsening heart failure and may be deteriorating for several reasons.

Odour, pain and a raised temperature can increase concern about infection, but no single feature confirms that a wound is infected. The patient needs prompt registered-professional and medical assessment.

Why Is This Patient at High Risk?

Several factors overlap:

• very limited mobility
• difficulty changing position independently
• prolonged chair sitting
• oedema and fragile skin
• moisture within skin folds
• acute illness
• possible poor nutritional intake
• pain during movement
• need for equipment that safely supports the patient’s body size

Body size alone does not cause pressure ulcers. The risk comes from the interaction between mobility, pressure, shear, moisture, perfusion, skin condition, nutrition, equipment and illness.

Do not let a high body mass index become a shortcut for blaming the patient.

The SSKIN Framework

Many UK clinical areas use SSKIN to organise pressure-ulcer prevention:

Surface: Is the mattress, chair or cushion suitable for the patient’s needs and body size?

Skin inspection: Has the whole skin surface been checked respectfully, including heels, sacrum, folds and areas under devices?

Keep moving: Can the patient reposition independently? What assistance, handling equipment and schedule are required?

Incontinence and moisture: What is exposing the skin to moisture, and how will cleansing, drying and protection be managed?

Nutrition and hydration: Is further assessment or dietetic support needed?

SSKIN helps organise care, but it does not replace clinical assessment or the local pressure-ulcer pathway.

Repositioning Is Individualised

Repositioning frequency should be based on the person’s risk, skin condition, comfort, mobility, clinical stability, support surface and local policy. It should be documented and reviewed when the patient’s condition changes.

A patient with heart failure may also struggle to tolerate certain positions because of breathlessness. The plan must balance pressure relief, respiratory comfort, haemodynamic stability, pain, dignity and safe moving and handling.

Use enough trained staff and the correct equipment. Never attempt an unsafe reposition because a chart says it is due.

How Would You Escalate?

Tell the registered nurse immediately and describe what you have actually observed.

You could say:

“I’m concerned about extensive skin damage. There is non-blanching sacral discolouration, purple discolouration over the right heel and moist broken skin across several folds. He has severe oedema and significant pain when repositioned. His respiratory rate is 26, oxygen saturation is 93% on room air and heart rate is 108. He needs an urgent full assessment, pressure-relief plan and review for possible infection and cardiac deterioration.”

This is clearer than saying, “His skin looks bad.”

What Might Happen Next?

The registered team may:

• complete and document a full pressure-ulcer risk and skin assessment
• calculate and escalate the NEWS2 result
• request urgent medical review
• involve tissue viability according to local criteria
• arrange an appropriate pressure-redistributing surface
• create an individual repositioning and moving plan
• assess pain and prescribed analgesia
• review continence, moisture and skin-fold care
• assess nutrition and hydration
• investigate infection when clinically indicated
• consider discharge, safeguarding or self-neglect support sensitively

Dressings, barrier products, antimicrobial treatment and wound photography should follow assessment, consent, formulary and local policy. A student should not independently select products or categorise complex wounds.

Document the Difference

Record each area by location and describe what you can see and feel.

Useful details may include:

• skin colour change compared with surrounding tissue
• whether discolouration blanches
• skin integrity
• wound size where trained and authorised
• tissue appearance
• exudate and odour
• temperature, firmness or bogginess
• pain
• moisture exposure
• actions taken and escalation times

Avoid documenting several different areas as one vague “pressure sore”. A sacral pressure injury and moisture damage in a skin fold are not interchangeable.

Dignity Is Clinical Care

The patient may feel exposed, ashamed or worried that staff are judging them.

Explain what you are doing, ask permission, use respectful language and keep the patient covered as much as possible.

Difficulty managing personal care may be linked to breathlessness, pain, reduced mobility, depression, unsuitable housing, lack of equipment or inadequate support. It deserves assessment, not a lecture.

The Student Nurse’s Role

You can make a real difference by noticing change early.

You can:

• inspect skin during care with consent and appropriate supervision
• report non-blanching or unusual discolouration
• recognise that moisture damage and pressure damage may coexist
• complete observations and escalate deterioration
• support safe repositioning within the handling plan
• protect dignity
• document what you observed and who you informed
• ask for help before attempting movement that is unsafe

You do not need to diagnose the wound before raising concern.

The Bleepbook Takeaway

Personal care is assessment time.

The skin may show risk and deterioration that is not visible on the monitor. Look carefully, separate pressure from moisture, respond to the whole clinical picture and escalate with specific findings.

References

National Institute for Health and Care Excellence. Pressure ulcers: prevention and management (CG179).

National Institute for Health and Care Excellence. Pressure ulcers quality standard (QS89).

NHS. Pressure ulcers.

Nursing and Midwifery Council. The Code.