Skin Care & Protection

Positioning & Pressure-Relieving Devices

Nutrition

Environmental Modification

Patient, Carer & Professional Education

Other Prevention Interventions

• To provide instruction regarding pressure ulcer risk assessment
• To identify risk factors associated with pressure ulcer development
• To explain the meaning of an individual's risk assessment score
• To present a comprehensive, holistic plan to prevent pressure ulcers in individuals at risk

• To present nursing best practice guidelines for risk assessment and prevention of pressure ulcers
• To assist nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers and provide direction to nurses in defining early interventions for pressure ulcer prevention, and to manage Stage I pressure ulcers

• United States
• Older adults with identified intrinsic and/or extrinsic risk factors for pressure ulcers

• Canada
• Adults from diverse practice settings who are at risk of developing pressure ulcers

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Patients
Students

Advanced Practice Nurses
Nurses

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

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 hrs
  • 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 Ulcer Risk).
• Document risk assessment scores and implement prevention protocols based on cutscore.

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.

Assessment

A head-to-toe skin assessment should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences.

(Level of Evidence = IV)

The client's risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, is recommended. Interventions should be based on identified intrinsic and extrinsic risk factors and those identified by a risk assessment tool, such as Braden's categories of sensory perception, mobility, activity, moisture, nutrition, friction, and shear. Risk assessment tools are useful as an aid to structure assessment.

(Level of Evidence = IV)

Clients who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction, and shear in all positions and during lifting, turning, and repositioning.

(Level of Evidence = IV)

All pressure ulcers are identified and staged using the NPUAP criteria.

(Level of Evidence = IV)

If pressure ulcers are identified, utilization of the RNAO best practice guideline Assessment and Management of Stage I to IV Pressure Ulcers is recommended.

(Level of Evidence = IV)

All data should be documented at the time of assessment and reassessment.

(Level of Evidence = IV)

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

Other care issues and interventions

• Do not massage reddened bony prominences
• 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])
• Manage moisture
  • Manage moisture by determining the cause, use absorbent pad that wicks moisture
  • Offer a bedpan or urinal in conjunction with turning schedules

A head-to-toe skin assessment should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences.

(Level of Evidence = IV)

Avoid massage over bony prominences.

(Level of Evidence = IIb)

Protect and promote skin integrity:

• Ensure hydration through adequate fluid intake.
• Individualize the bathing schedule.
• Avoid hot water and use a pH balanced, non-sensitizing skin cleanser.
• Minimize force and friction on the skin during cleansing.
• Maintain skin hydration by applying non-sensitizing, pH balanced, lubricating moisturizers and creams with minimal alcohol content.
• Use protective barriers (e.g., liquid barrier films, transparent films, hydrocolloids) or protective padding to reduce friction injuries.

(Level of Evidence = IV)

Protect skin from excessive moisture and incontinence:

• Assess and manage excessive moisture related to body fluids (e.g., urine, feces, perspiration, wound exudates, saliva)
• Gently cleanse skin at time of soiling. Avoid friction during care with the use of a spray perineal cleaner or soft wipe.
• Minimize skin exposure to excess moisture. When moisture cannot be controlled, use absorbent pads, dressings, or briefs that wick moisture away from the skin. Replace pads and linens when damp.
• Use topical agents that provide protective barriers to moisture.
• If unresolved skin irritation exists in a moist area, consult with the physician for evaluation and topical treatment.
• Establish a bowel and bladder program.

(Level of Evidence = IV)

Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality, AHRQ) (AHCPR, 1992) prevention recommendations:

• Turn and position bed-bound 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 bed-bound 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 clients are 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.
• Avoid positioning the patient directly on their trochanter.
• Avoid use of doughnut-shaped devices.
• 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 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.

For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule.

(Level of Evidence = IV)

Use proper positioning, transferring, and turning techniques. Consult Occupational Therapy/Physiotherapy (OT/PT) regarding transfer and positioning techniques and devices to reduce friction and shear and to optimize client independence.

(Level of Evidence = IV)

Clients at risk of developing a pressure ulcer should not remain on a standard mattress. A replacement mattress with low interface pressure, such as high-density foam, should be used.

(Level of Evidence = Ia)

For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intraoperatively should be considered.

(Level of Evidence = Ia)

For individuals restricted to bed:

• Utilize an interdisciplinary approach to plan care.
• Use devices to enable independent positioning, lifting, and transfers (e.g., trapeze, transfer board, bed rails).
• Reposition at least every 2 hours or sooner if at high risk.
• Use pillows or foam wedges to avoid contact between bony prominences.
• Use devices to totally relieve pressure on the heels and bony prominences of the feet.
• A 30 degree turn to either side is recommended to avoid positioning directly on the trochanter.
• Reduce shearing forces by maintaining the head of the bed at the lowest elevation consistent with medical conditions and restrictions. A 30 degree elevation or lower is recommended.
• Use lifting devices to avoid dragging clients during transfer and position changes.
• Do not use donut type devices or products that localize pressure to other areas.

(Level of Evidence = IV)

For individuals restricted to chair:

• Use an interdisciplinary approach to plan care.
• Have the client shift weight every 15 minutes, if able.
• Reposition at least every hour if unable to shift weight.
• Use pressure-reducing devices for seating surfaces.
• Do not use donut type devices or products that localize pressure to other areas.
• Consider postural alignment, distribution of weight, balance, stability, support of feet, and pressure reduction when positioning individuals in chairs or wheelchairs.
• Refer to OT/PT for seating assessment and adaptations for special needs.

(Level of Evidence = IV)

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.

A nutritional assessment with appropriate interventions should be implemented on entry to any new health care environment and when the client's condition changes. If a nutritional deficit is suspected:

• Consult with a registered dietitian. (Level of Evidence = IV)
• Investigate factors that compromise an apparently well nourished individual's dietary intake (especially protein or calories) and offer him or her support with eating. (Level of Evidence = IV)
• Plan and implement a nutritional support and/or supplementation program for nutritionally compromised individuals. (Level of Evidence = IV)
• If dietary intake remains inadequate, consider alternative nutritional interventions. (Level of Evidence = IV)
• Nutritional supplementation for critically ill older clients should be considered. (Level of Evidence = Ib)

Other Care Issues and Interventions

Teach patient, caregivers, and staff the prevention protocols

Education Recommendations

Educational programs for the prevention of pressure ulcers should be structured, organized, and comprehensive and should be updated on a regular basis to incorporate new evidence and technologies. Programs should be directed at all levels of health care providers including clients, family or caregivers. (Level of Evidence = III)

The educational program for prevention of pressure ulcers should be based on the principles of adult learning, the level of information provided and the mode of delivery. Programs must be evaluated for their effectiveness in preventing pressure ulcers through such mechanisms as quality assurance standards and audits. Information on the following should be included:

• The etiology and risk factors predisposing to pressure ulcer development.
• The use of risk assessment tools, such as the Braden Scale for Predicting Pressure Score Risk. Categories of the risk assessment should also be utilized to identify specific risks and ensure effective care planning.
• Skin assessment.
• Staging of pressure ulcers.
• Selection and/or use of support surfaces.
• Development and implementation of an individualized skin care program.
• Demonstration of positioning/transferring techniques to decrease risk of tissue breakdown.
• Instruction on accurate documentation of pertinent data.
• Roles and responsibilities of team members in relation to pressure ulcer risk assessment and prevention.

(Level of Evidence = III)

Follow-up Monitoring of Condition

• Monitor effectiveness of prevention interventions.
• Monitor healing of any existing pressure ulcers.

An individualized plan of care is based on assessment data, identified risk factors, and the client's goals. The plan is developed in collaboration with the client, significant others, and health care professionals.

(Level of Evidence = IV)

The nurse uses clinical judgment to interpret risk in the context of the entire client profile, including the client's goals.

(Level of Evidence = IV)

Consider the impact of pain. Pain may decrease mobility and activity. Pain control measures may include effective medication, therapeutic positioning, support surfaces, and other non-pharmacological interventions. Monitor level of pain on an on-going basis, using a valid pain assessment tool.

(Level of Evidence = IV)

Consider the client's risk for skin breakdown related to the loss of protective sensation or the ability to perceive pain and to respond in an effective manner (e.g., impact of analgesics, sedatives, neuropathy, etc.)

(Level of Evidence = IV)

Consider the impact of pain on local tissue perfusion

(Level of Evidence = IV)

Institute a rehabilitation program, if consistent with the overall goals of care and the potential exists for improving the individual's mobility and activity status. Consult the care team regarding a rehabilitation program.

(Level of Evidence = IV)

Advance notice should be given when transferring a client between setting (e.g., hospital to home/long-term care facility/hospice/residential care) if pressure reducing/relieving equipment is required to be in place at time of transfer (e.g., pressure relieving mattresses, seating, special transfer equipment). Transfer to another setting may require a site visit, client/family conference, and/or assessment for funding of resources to prevent the development of pressure ulcers.

(Level of Evidence = IV)

Clients moving between care settings should have the following information provided:

• Risk factors identified
• Details of pressure points and skin condition prior to discharge
• Type of bed/mattress the client requires
• Type of seating the client requires
• Details of healed ulcers
• Stage, site, and size of existing ulcers
• History of ulcers, previous treatments, and products used
• Type of dressing currently used and frequency of change
• Adverse reactions to wound care products
• Summary of relevant laboratory results
• Need for on-going nutritional support

(Level of Evidence = IV)

Patient

• Skin will remain intact.
• Pressure ulcer(s) will heal.

Provider/Nurse

• Accurate performance of pressure ulcer risk assessment using standardized tool.
• Implementation of pressure ulcer prevention protocols for clients interpreted as at risk for pressure ulcers.
• Performance of a skin assessment for early detection of pressure ulcers.

Institutional

• Reduction in development of new pressure ulcers.
• Increased number of risk assessments performed.
• Cost-effective prevention protocols developed.

• Accurate identification of at-risk individuals who need preventive interventions and of the specific factors that place them at risk
• Protection and promotion of skin integrity
• Protection against the forces of pressure, friction, and shear
• Reduction of the incidence of pressure ulcers through educational programs for health professionals and clients
• Nurses, other health care professionals, and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment, and documentation tools, etc.

Not stated

Not stated

Levels of Evidence

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

REFERENCES SUPPORTING THE RECOMMENDATIONS

Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults: prediction and prevention. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, AHCPR; 1992 May. 63 p. (Clinical practice guideline; no. 3). [127 references]

Ayello EA, Braden B. Why is pressure ulcer risk assessment so important? Nursing 2001 Nov;31(11):74-9.

Bank D. Decreasing the incidence of skin tears in a nursing and rehabilitation center. Adv Skin Wound Care 2005;18:74-5.

Baranoski S, Ayello EA. Wound care essentials: practice principles. Springhouse (PA): Lippincott, Williams, & Wilkins; 2004. 54-8 p.

Baranoski S. Skin tears: the enemy of frail skin. Adv Skin Wound Care 2000;13(3):123-6.

Birch S, Coggins T. No-rinse, one-step bed bath: the effects on the occurrence of skin tears in a long-term care setting. Ostomy Wound Manage 2003 Jan;49(1):64-7. PubMed

Centers for Medicare & Medicaid Services (CMS). Guidance for surveyors in long term care: Tag F 314: pressure ulcers. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2004.

Gilcreast DM, Warren JB, Yoder LH, Clark JJ, Wilson JA, Mays MZ. Research comparing three heel ulcer-prevention devices. J Wound Ostomy Continence Nurs 2005 Mar-Apr;32(2):112-20. PubMed

Hampton S, Collins F. Reducing pressure ulcer incidence in a long-term setting. Br J Nurs 2005 Aug 11-Sep 7;14(15):S6-12. PubMed

Hanson DH, Anderson J, Thompson P, Langemo D. Skin tears in long-term care: effectiveness on skin care protocols on prevalence. Adv Skin Wound Care 2005;18:74.

Houwing RH, Rozendaal M, Wouters-Wesseling W, Beulens JW, Buskens E, Haalboom JR. A randomised, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients. Clin Nutr 2003 Aug;22(4):401-5. PubMed

Hunter S, Anderson J, Hanson D, Thompson P, Langemo D, Klug MG. Clinical trial of a prevention and treatment protocol for skin breakdown in two nursing homes. J Wound Ostomy Continence Nurs 2003 Sep;30(5):250-8. PubMed

Iglesias C, Nixon J, Cranny G, Nelson EA, Hawkins K, Phillips A, Torgerson D, Mason S, Cullum N, PRESSURE Trial Group. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. BMJ 2006 Jun 17;332(7555):1416. PubMed

Mason SR. Type of soap and the incidence of skin tears among residents of a long-term care facility. Ostomy Wound Manage 1997 Sep;43(8):26-30. PubMed

Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993 Jun;39(5):16-20, 22-4, 26. PubMed

White MW, Karam S, Cowell B. Skin tears in frail elders: a practical approach to prevention. Geriatr Nurs 1994 Mar-Apr;15(2):95-9. PubMed

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities