Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.
Pressure Ulcers
Parameters of Assessment
- Assess for intrinsic and extrinsic risk factors
- Braden Scale risk score
- 18 or below for elderly and persons with darkly pigmented skin
- 16 or below for other adults
Nursing Care Strategies and Interventions
Follow-up Monitoring of Condition
- Monitor effectiveness of prevention interventions.
- Monitor healing of any existing pressure ulcers.
Skin Tears
Parameters of Assessment
- Use the three-group risk assessment tool (White, Karam & Cowell, 1994 [Level IV]) to assess for skin tear risk.
- Use the Payne and Martin (1993 [Level IV]) classification system to assess clients for skin tear risk:
- Category I: a skin tear without tissue loss
- Category II: a skin tear with partial tissue loss
- Category III: a skin tear with complete tissue loss, where the epidermal flap is absent
Nursing Care Strategies and Interventions (Baranoski, 2000 [Level V])
- Preventing skin tears
- Provide a safe environment:
- Do a risk assessment of elderly patients on admission.
- Implement prevention protocol for patients identified as at risk for skin tears.
- Have patients wear long sleeves or pants to protect their extremities (Bank, 2005 [Level IV]).
- Have adequate light to reduce the risk of bumping into furniture or equipment.
- Provide a safe area for wandering.
- Educate staff or family caregivers in the correct way of handling patients to prevent skin tears. Maintain nutrition and hydration:
- Offer fluids between meals.
- Use lotion, especially on dry skin on arms and legs, twice daily (Hanson et al., 2005 [Level III]).
- Obtain a dietary consult.
- Protect from self-injury or injury during routine care:
- Use a lift sheet to move and turn patients.
- Use transfer techniques that prevent friction or shear.
- Pad bedrails, wheelchair arms, and leg supports (Bank, 2005 [Level IV]).
- Support dangling arms and legs with pillows or blankets.
- Use non-adherent dressings on frail skin.
- Apply petroleum-based ointment, steri-strips, or a moist nonadherent wound dressing such as hydrogel dressing with gauze as a secondary dressing. Telfa type dressings are also used.
- If you must use tape, be sure it is made of paper, and remove it gently. Also, you can apply the tape to hydrocolloid strips placed strategically around the wound rather than taping directly onto fragile surrounding skin around the skin tear.
- Use gauze wraps, stockinettes, flexible netting, or other wraps to secure dressings rather than tape.
- Use no-rinse soapless bathing products (Birch & Coggins, 2003 [Level IV]; Mason, 1997 [Level IV]).
- Keep skin from becoming dry, apply moisturizer (Hanson et al., 2005 [Level III]; Bank, 2005 [Level IV]).
- Treating skin tears (Baranoski & Ayello, 2004 [Level V])
- Gently clean the skin tear with normal saline.
- Let the area air dry or pat dry carefully.
- Approximate the skin tear flap.
- Use caution if using film dressings as skin damage can occur when removing dressings.
- Consider putting an arrow to indicate the direction of the skin tear on the dressing to minimize any further skin injury during dressing removal.
- Skin sealants, petroleum-based products, and other water-resistant product such as protective barrier ointments or liquid barriers may be used to protect the surrounding skin from wound drainage or dressing/tape removal trauma.
- Always assess the size of the skin tear, consider doing a wound tracing.
- Document assessment and treatment findings.
Follow-up Monitoring of Condition
Continue to reassess for any new skin tears in older adults.
Definitions:
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.