The skin is the largest external organ, so preserving its integrity is an important aspect of nursing care. Performing a risk assessment and implementing a consistent prevention protocol may avoid some losses of skin integrity including pressure ulcers or skin tears. Although pressure ulcers and skin tears may look similar, they are different types of injury; skin tears are acute traumatic wounds, whereas pressure ulcers are chronic wounds. It is important, therefore, to assess the wound and determine the correct etiology so that the proper individualized treatment plan can be implemented.
Nursing Standard of Practice Protocol: Pressure Ulcer Prevention & Skin Tear Prevention
Elizabeth A. Ayello, PhD, RN, APRN,BC, CWOCN, FAPWCA, FAAN , R. Gary Sibbald, MD, FRCPC(C)
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.
The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:
Pressure Ulcer - Goals
- Prevention of pressure ulcers (PU).
- Early recognition of PU development/skin changes.
Pressure Ulcer - Background and Statement of Problem
- Pressure ulcer 2009: Occurrence data reported for 2009 (VanGilder et al., 2009)
- All U.S. facilities
- Overall Prevalence: 12.3%
- Facilitiy acquired (FA) prevalence: 5.0%
- Prevalence excluding Stage 1: 9.0%
- FA prevalence excluding Stage 1: 3.2%
- Acute care
- Etiology and/or epidemiology
- Risk factors (immobility, under or malnutrition, incontinence, friable skin, impaired cognitive ability)
- Higher incidence stage II and higher in persons with darkly pigmented skin
Pressure Ulcers - Parameters of Assessment
- Perform complete skin assessment as part of the risk assessment policy and practices (EPUAP & NPUAP, 2009)
- Inspect skin regularly for color changes such as redness in lightly pigmented persons and discoloration in darkly pigmented persons (EPUAP & NPUAP, 2009)
- Look at the skin under any medical device (e.g., catheters, oxygen, airway or ventilator tubing, face masks, braces, collars).
- Palpate skin for changes in temperature (warmth) edema or hardness
- Ask the patient if they have any areas of pain or discomfort over bony prominences
- Assess for intrinsic and extrinsic risk factors
- Braden scale risk score--18 or less for older adults and persons with darkly pigmented skin
Pressure Ulcers - Nursing Care Strategies and Interventions
- Risk assessment documentation
- On admission to acute care
- Reassessment intervals whenever the client's condition changes and based on patient care setting:
- Based on patient acuity every 24-48 hours in general units
- Critically ill patients every 12 hours
- Use a reliable and standardized tool for doing a risk assessment, such as the Braden Scale as part of a comprehensive risk assessment. See:
- Try This Issue 5 - Predicting Pressure Ulcer Risk
- Document risk assessment scores and implement prevention protocols based on overall scores, low subscores, and the comprehensive assessment of other risk factors.
- Assess risk of surgical patients for increased risk of pressure ulcers including the following factors: length of operation, number of hypotensive episodes, and/or low-core temperatures intraoperatively, reduced mobility on first day postoperatively.
- 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 or other discoloration based on patient's skin tone.
- Compare skin over bony prominences to surrounding skin - may be boggy or stiff, warm or cooler.
- Prevention recommendations:
- Skin care (EPUAP & NPUAP, 2009)
- Assess skin regularly.
- Clean skin at time of soiling; avoid hot water and irritating cleaning agents.
- Use emollients on dry skin.
- Do not massage bony prominences as a pressure ulcer prevention strategy as well as do not vigorously rub skin at risk for pressure ulcers.
- Protect skin from moisture-associated damage (e.g., urinary and/or fecal incontinence, perspiration, wound exudates) by using barrier products.
- Use lubricants, protective dressings, and proper lifting techniques to avoid skin injury from friction/shear during transferring and turning of clients. Avoid drying out the patient's skin; use lotion after bathing.
- Avoid hot water and soaps that are drying when bathing older adults. Use body wash and skin protectant (Hunter et al., 2003).
- Teach patient, caregivers, and staff the prevention protocol.
- Manage moisture by determining the cause; use absorbent pad that wicks moisture.
- Protect high-risk areas such as elbows, heels, sacrum, and back of head from friction injury.
- Repositioning and support surfaces
- Keep patients off the reddened areas of skin
- Repositioning schedules should be individualized based on the patient's condition, care goals, vulnerable skin areas, and type of support surface being used (EPUAP & NPUAP, 2009).
- Communicate the repositioning schedule to all the patient's caregivers.
- Raise heels of bed-bound clients off the bed; do not use donut-type devices.4
- 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 using either pillows or heel-protection devices; do not use donut-type devices.4
- Use a 30-degree tilted side lying position; do not place clients directly in a 90 degree side lying position on their trochanter.
- Keep head of the bed at lowest height possible.
- Use transfer and 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 or water mattresses).5, 6 Use higher specification foam mattresses rather than standard hospital mattresses for patients at risk for pressure ulcers. If the patient cannot be frequently repositioned manually, use an active support surface (overlay or mattress).
- Use pressure redistributing mattresses on the operating table for patients identified at risk for developing pressure ulcers.
- Reposition chairbound or wheelchair-bound clients every hour. In addition, if client is capable, have him or her do small weight shifts every 15 minutes.
- Use a pressure-reducing device (not a donut) for chairbound clients.
- Keep the patient as active as possible; encourage mobilization.
- Avoid positioning the patient directly on his or her trochanter.
- Avoid using donut-shaped devices.
- Offer a bedpan or urinal in conjunction with turning schedules
- 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.
- Assess nutritional status of patients at risk for pressure ulcers.
- For at-risk patient, follow nutritional guidelines for hydration (1 ml/kcal of fluid per day) and calories (30-35 kcal/kg of body weights per day), protein 1.25-1.5 g/kg per day). Give high-protein supplements or tube feedings in addition to the usual diet in persons at nutritional and pressure ulcer risk (EPUAP & NPUAP, 2009).
- Manage nutrition
- Consult a dietitian and correct nutritional deficiencies by increasing protein and calorie intake and A, C, or E vitamin supplements as needed (CMS, 2004; Houwing et al., 2003).
- Offer a glass of water during turning schedules to keep patient hydrated.
- Interventions Linked to Braden Risk Scores Adapted 10
Prevention protocols linked to Braden risk scores are as follows:
- At risk: score of 15-18
- Frequent repositioning turning; use a written schedule.
- Maximize patient's mobility.
- Protect patient's heels.
- Use a pressure-reducing support surface if patient is bedbound or chairbound.
- Moderate risk: score of 13-14
- Same as above, but provide foam wedges for 30-degree lateral position.
- High risk: score of 10-12
- 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.
Pressure Ulcer - Evaluation and Expected Outcomes
- Skin will remain intact
- Pressure ulcer(s) will heal
- Nurses will accurately perform PU risk assessment using standardized tool
- Nurses will implement PU prevention protocols for clients interpreted as at risk for PU.
- Nurses will perform a skin assessment for early detection of pressure ulcers.
- Reduction in development of new pressure ulcers.
- Increased number of risk assessments performed.
- Cost-effective prevention protocols developed.
Pressure Ulcer - Follow-up Monitoring of Condition
- Monitor effectiveness of prevention interventions
- Monitor healing of any existing pressure ulcers
Standard of Practice Protocol: Skin Tear Prevention
Elizabeth Ayello and R.Gary Sibbald
Skin Tears - Goals
- Prevent skin tears in elderly clients.
- Identify clients at risk for skin tears (Mason, 1997).
- Foster healing of skin tears by
- Retaining skin flap
- Providing a moist, nonadherent dressing. 12, 13
- Protecting the site from further injury
Skin Tears - Background and Statement of Problem
- Traumatic wounds from mechanical injury of skin
- Need to clearly differentiate etiology of skin tears from pressure ulcers
- Common in the elderly, especially over areas of age-related purpura
Skin Tears - Parameters of Assessment
- Use the three-group risk assessment tool 11 to assess for skin tear risk.
- Use the Payne and Martin 14 classification system to assess clients for skin tear risk:
1. Category I: a skin tear without tissue loss
2. Category II: a skin tear with partial tissue loss
3. Category III: a skin tear with complete tissue loss, where epidermal flap absent
Skin Tears - Nursing Care Strategies and Interventions (Ref 15; Ref 20) 15
- 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.16
- 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., 1991).
- Obtain a dietary consultation.
- 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. 16
- Support dangling arms and legs with pillows or blankets.
- Use nonadherent 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, silicone, or Telfa-type dressings.
- 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.17, 18
- Keep skin from becoming dry, apply moisturizer (Ref16;Hanson et al., 1991). 16
- Treating Skin Tears 20
- 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 adherent 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, or tape removal trauma.
- Always assess the size of the skin tear; consider doing a wound tracing.
- Document assessment and treatment findings.
Skin Tears - Evaluation and Expected Outcomes
- No skin tears will occur in at-risk clients.
- Skin tears that do occur will heal.
Skin Tears - Follow-up Monitoring of Condition
- Continue to reassess for any new skin tears in older adults.
- Gilcreast, D. M., Warren, J. B., Yoder, L. H., Clark, J. J., Wilson, J. A., & Mays, M. Z. (2005). Research comparing three heel ulcer-prevention devices. Journal of Wound, Ostomy, and Continence Nursing, 32(2), 112-120. Evidence Level II: Single Experimental Study.
- Iglesias, D., Nixon, J., Cranny, G., Nelson, E. A., Hawkins, K., Phillips, A., et al. (2006). Pressure relieving support surfaces (PRESSURE) Trial: Cost-effectiveness analysis. British Medical Journal, 332(7555), 1416. Evidence Level II: Single Experimental Study.
- Hampton, S., & Collins, F. (2005). Reducing pressure ulcer incidence in a long-term setting. British Journal of Nursing, 14(15), S6-S12. Evidence Level II: RCT.
- Hunter, S., Anderson, J., Hanson, D., Thompson, O., Langemo, D., & Klug, M. G. (2003). Clinical trial of a prevention treatment protocol for skin breakdown in two nursing homes. Journal of Wound, Ostomy, and Continence Nurses Society (WOCN), 30(5), 250-258. Evidence Level III: Quasi-experimental Study.
- Houwing, R. H., Rozendaal, M.,Wouters-Wesseling,W., Beulens, J.W., & Buskens, E. (2003). A randomised, double-bind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients. Clinical Nutrition, 22(4), 401-405. Evidence Level II: RCT.
- Ayello, E. A., & Braden, B. (2001). Why is pressure ulcer risk so important? Nursing, 31(11), 74-79. Evidence Level V: Review.
- White, M. W., Karam, S., & Cowell, B. (1994). Skin tears in frail elders: A practical approach to prevention. Geriatric Nursing, 15(2), 95-98. Evidence Level IV: Nonexperimental Study.
- Edwards, H., Gaskill, D., & Nash, R. (1998). Treating skin tears in nursing home residents: A pilot study comparing four types of dressings. International Journal of Nursing Practice, 4, 25-32. Evidence Level III: Quasi-experimental Study.
- Thomas, D. R., Goode, P. S., LaMaster, K., Tennyson, T., & Parnell, L. K. S. (1999). A comparison of an opaque foam dressing versus a transparent film dressing in the management of skin tears in institutionalized subjects. Ostomy/Wound Management, 45(6), 22-28. Evidence Level III: Quasi-experimental Study.
- Payne, R. L., & Martin, M. C. (1993). Defining and classifying skin tears: Need for common language. Ostomy/Wound Management, 39(5), 16-19, 22-24, 26. Evidence Level IV: Nonexperimental Study.
- Baranoski, S. (2000). Skin tears: The enemy of frail skin. Advances in Skin and Wound Care, 13(3), 123-126. Evidence Level V: Review.
- Bank, D. (2005). Decreasing the incidence of skin tears in a nursing and rehabilitation center. Advances in Skin and Wound Care, 18, 74-75. Evidence Level IV: Nonexperimental Study.
- Birch, S., & Coggins, T. (2003). Non-rinse, one-step bed bath: The effects on the occurrence of skin tears in a long-term-care setting. Ostomy/Wound Management, 49, 64-67. Evidence Level IV: Nonexperimental Study.
- Mason, S. R. (1997). Type of soap and the incidence of skin tears among residents of a long-term-care facility. Ostomy/Wound Management, 43(8), 26-30. Evidence Level IV: Nonexperimental Study.
- Baranoski, S., & Ayello, E. A. (2008). Wound care essentials: Practice principles (pp. 54-58 ). Springhouse, PA: Lippincott, Williams, & Wilkins. Evidence Level V.
- VanGilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009). Results of the 2008-2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy/Wound Management, 55(11), 39-45. Evidence Level IV.
- European Pressure Ulcer Advisory Panel, & National Pressure Ulcer Advisory Panel. (2009). Treatment of pressure ulcers: Quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel. Evidence Level I.
- Hanson, D., Langemo, D.K., Olson, B., Hunter, S., Sauvage, T.R., Burd, C., & Carthcart-Silberberg, T. (1991). The prevalence and incidence of pressure ulcers in the hospice setting: Analysis of two methodologies. American Journal of Hospice & Palliative Care, 8(5), 18-22. Evidence Level IV.
Last updated - July 2012
Stotts, N.A., & Gunningberg, L. (2007). How to try this: Predicting pressure ulcer risk. AJN, 107(11), 40-48. Available online at http://www.nursingcenter.com/prodev/ce_article.asp?tid=751548
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Braden, B.J., & Maklebust, J. (2005). Preventing pressure ulcers with the Braden Scale: An update on this easy-to-use tool that assesses a patient's risk. AJN, 105(6), 70-72.
Last updated - July 2009