• Risk assessment documentation
  • On admission to a facility
  • Reassessment intervals whenever the client´s condition changes and based on patient care setting:
    • Acute care: every 48 hours
    • Long-term care: weekly for first 4 weeks, then monthly to quarterly
    • Home care: every nursing visit
  • Use a reliable and standardized tool for doing a risk assessment such as the Braden Scale (see "Try This: Predicting Pressure Ulcers" in Resources at www.ConsultGeriRN.org)
  • Document risk assessment scores and implement prevention protocols based on cut score
• General care issues and interventions
  • Culturally sensitive early assessment for stage I pressure ulcers in clients with darkly pigmented skin
    • Use a halogen light to look for skin color changes--may be purple hues
    • Compare skin over bony prominences to surrounding skin--may be boggy or stiff, warm or cooler
  • Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality, AHRQ) (AHCPR, 1992) prevention recommendations:
    • Assess skin daily.
    • Clean skin at time of soiling; avoid hot water and irritating cleaning agents.
    • Use moisturizers on dry skin.
    • Do not massage bony prominences.
    • Protect skin of incontinent clients from exposure to moisture.
    • Use lubricants, protective dressings, and proper lifting techniques to avoid skin injury from friction/shear during transferring and turning of clients.
    • Turn and position bedbound clients every 2 hours if consistent with overall care goals.
    • Use a written schedule for turning and repositioning clients.
    • Use pillows or other devices to keep bony prominences from direct contact with each other.
    • Raise heels of bedbound clients off the bed; do not use donut-type devices (Gilcreast, et al. 2005 [Level II]).
    • Use a 30-degree lateral side lying position; do not place client directly on their trochanter.
    • Keep head of the bed at lowest height possible.
    • Use lifting devices (trapeze, bed linen) to move clients rather than dragging them in bed during transfers and position changes.
    • Use pressure-reducing devices (static air, alternating air, gel, water mattresses) (Iglesias et al., 2006 [Level II]; Hampton & Collins, 2005 [Level II]).
    • Reposition chair or wheelchair bound clients every hour. In addition, if client is capable, have them do small weight shifts every 15 minutes.
    • Use a pressure-reducing device (not a donut) for chair-bound clients.
  • Other care issues and interventions
    • Keep the patient as active as possible; encourage mobilization.
    • Do not massage reddened bony prominences.
    • Avoid positioning the patient directly on their trochanter.
    • Avoid use of donut-shaped devices.
    • Avoid drying out the patient's skin; use lotion after bathing.
    • Avoid hot water and soaps that are drying when bathing elderly. Use body wash and skin protectant (Hunter et al., 2003 [Level III]).
    • Teach patient, caregivers, and staff the prevention protocols.
    • Manage moisture:
      • Manage moisture by determining the cause; use absorbent pad that wicks moisture.
      • Offer a bedpan or urinal in conjunction with turning schedules.
    • Manage nutrition:
      • Consult a dietician and correct nutritional deficiencies
      • Increase protein and calorie intake and A, C, or E vitamin supplements as needed (Houwing et al., 2003 [Level II]; Centers for Medicare and Medicaid Services [CMS], 2004 [Level V]).
      • Offer a glass of water with turning schedules to keep patient hydrated.
    • Manage friction and shear:
      • Elevate the head of the bed no more than 30 degrees.
      • Have the patient use a trapeze to lift self up in bed.
      • Staff should use a lift sheet or mechanical lifting device to move patient.
      • Protect high-risk areas such as elbows, heels, sacrum, back of head from friction injury.
• Interventions linked to Braden risk scores (Adapted from Ayello & Braden, 2001)

  Prevention protocols linked to Braden risk scores are as follows:

  • At-risk: score of 15 to 18
    • Frequent turning; consider every 2 hour schedule; use a written schedule.
    • Maximize patient's mobility.
    • Protect patient's heels.
    • Use a pressure-reducing support surface if patient is bed- or chair-bound.
  • Moderate risk: score of 13 to 14
    • Same as above but provide foam wedges for 30-degree lateral position.
  • High risk: score of 10 to 12
    • Same as above, but add the following:
      • Increase the turning frequency.
      • Do small shifts of position.
  • Very high risk: score of 9 or below
    • Same as above, but use a pressure relieving surface.
    • Manage moisture, nutrition, and friction/shear.

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, (3^rd ed). New York: Springer Publishing Company.

References open in a new window

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Geriatric Nursing Protocols for Best Practice, 3rd edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

• Predicting pressure ulcer risk. Try this: best practices in nursing care to older adults. 2007. Electronic copies available from the Hartford Institute for Geriatric Nursing Web site.
• Nursing care strategies/treatment/management and pressure ulcer staging system are available from the Hartford Institute for Geriatric Nursing Web site.
• Pressure ulcers/skin tears: post-test instructions are available from the Continuing education activity. Available from the Hartford Institute for Geriatric Nursing Web site.

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