Want to know more

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)

 

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Nursing Standard of Practice Protocol: Pressure Ulcer Prevention

Pressure Ulcer - Goals

  1. Prevention of pressure ulcers (PU).
  2. Early recognition of PU development/skin changes.
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Pressure Ulcer - Background and Statement of Problem

  1. Prevalence: 15% 1
    1. Acute-care range: 10% to 18%
    2. Long-term-care range: 2.3% to 28%
    3. Home-care range: 0% to 29%
  2. Incidence: 7%
    1. Acute-care range: 0.4% to 38%
    2. Long-term-care range: 2.2% to 23.9%
    3. Home-care range: 0% to 17%
  3. Healthy People 2010 Objective: Reduce the proportion of nursing-home residents with a current diagnosis of pressure ulcers
  4. A sentinel event in long-term care 2
  5. Etiology and/or epidemiology
    1. Risk factors (immobility, under or malnutrition, incontinence, friable skin, impaired cognitive ability)
    2. Higher incidence stage II and higher in persons with darkly pigmented skin
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Pressure Ulcers - Parameters of Assessment

  1. Assess for intrinsic and extrinsic risk factors
  2. Braden Scale risk score
    1. 18 or below for elderly and persons with darkly pigmented skin
    2. 16 or below for other adults
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Pressure Ulcers - Nursing Care Strategies and Interventions

  1. Risk assessment documentation
    1. On admission to a facility.
    2. Reassessment intervals whenever the client's condition changes and based on patient care setting:
      1. acute care: every 48 hours.
      2. long-term care: weekly for first 4 weeks, then monthly/quarterly.
      3. home care: every nursing visit.
    3. Use a reliable and standardized tool for doing a risk assessment, such as the Braden Scale. See:
    4. Document risk assessment scores and implement prevention protocols based on cut score.
  2. General Care Issues and Interventions
    1. Culturally sensitive early assessment for stage I pressure ulcers in clients with darkly pigmented skin:
      1. Use a halogen light to look for skin color changes - may be purple hues.
      2. Compare skin over bony prominences to surrounding skin - may be boggy or stiff, warm or cooler.
    2. AHCPR (1992) prevention recommendations:3
      1. Assess skin daily.
      2. Clean skin at time of soiling; avoid hot water and irritating cleaning agents.
      3. Use moisturizers on dry skin.
      4. Do not massage bony prominences.
      5. Protect skin of incontinent clients from exposure to moisture.
      6. Use lubricants, protective dressings, and proper lifting techniques to avoid skin injury from friction/shear during transferring and turning of clients.
      7. Turn and position bed-bound clients every 2 hours if consistent with overall care goals.
      8. Use a written schedule for turning and repositioning clients.
      9. Use pillows or other devices to keep bony prominences from direct contact with each other.
      10. Raise heels of bed-bound clients off the bed; do not use donut-type devices.4
      11. Use a 30-degree lateral side lying position; do not place clients directly on their trochanter.
      12. Keep head of the bed at lowest height possible.
      13. Use lifting devices (trapeze, bed linen) to move clients rather than dragging them in bed during transfers and position changes.
      14. Use pressure-reducing devices (static air, alternating air, gel or water mattresses).5, 6
      15. Reposition chair- or wheelchair-bound clients every hour. In addition, if client is capable, have him or her do small weight shifts every 15 minutes.
      16. Use a pressure-reducing device (not a donut) for chair-bound clients.
    3. Other care issues and interventions
      1. Keep the patient as active as possible; encourage mobilization.
      2. Do not massage reddened bony prominences.
      3. Avoid positioning the patient directly on his or her trochanter.
      4. Avoid using donut-shaped devices.
      5. Avoid drying out the patient's skin; use lotion after bathing.
      6. Avoid hot water and soaps that are drying when bathing elderly. Use body wash and skin protectant.7
      7. Teach patient, caregivers, and staff the prevention protocols.
      8. Manage moisture:
        1. Manage moisture by determining the cause; use absorbent pad that wicks moisture.
        2. Offer a bedpan or urinal in conjunction with turning schedules.
      9. Manage nutrition:
        1. Consult a dietitian, and correct nutritional deficiencies
        2. Increase protein and calorie intake and A, C, or E vitamin supplements as needed. 8, 9
        3. Offer a glass of water with turning schedules to keep patient hydrated.
      10. Manage friction and shear:
        1. Elevate the head of the bed no more than 30 degrees.
        2. Have the patient use a trapeze to lift self up in bed.
        3. Staff should use a lift sheet or mechanical lifting device to move patient.
        4. Protect high-risk areas such as elbows, heels, sacrum, and back of head from friction injury.
  3. Interventions Linked to Braden Risk Scores Adapted 10
    Prevention protocols linked to Braden risk scores are as follows:
    1. At risk: score of 15-18
      1. Frequent turning; consider q 2 h schedule; use a written schedule.
      2. Maximize patient's mobility.
      3. Protect patient's heels.
      4. Use a pressure-reducing support surface if patient is bed- or chair-bound.
    2. Moderate risk: score of 13-14
      1. Same as above, but provide foam wedges for 30-degree lateral position.
    3. High risk: score of 10-12
      1. Same as above, but add the following.
        1. Increase the turning frequency.
        2. Do small shifts of position.
    4. Very high risk: score of 9 or below
      1. Same as above, but use a pressure-relieving surface.
      2. Manage moisture, nutrition, and friction/shear.
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Pressure Ulcer - Evaluation and Expected Outcomes

  1. Patients
    1. Skin will remain intact
    2. Pressure ulcer(s) will heal
  2. Provider/Nurse
    1. Nurses will accurately perform PU risk assessment using standardized tool
    2. Nurses will implement PU prevention protocols for clients interpreted as at risk for PU.
    3. Nurses will perform a skin assessment for early detection of pressure ulcers.
  3. Institution
    1. Reduction in development of new pressure ulcers.
    2. Increased number of risk assessments performed.
    3. Cost-effective prevention protocols developed.
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Pressure Ulcer - Follow-up Monitoring of Condition

  1. Monitor effectiveness of prevention interventions
  2. Monitor healing of any existing pressure ulcers

 

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Standard of Practice Protocol: Skin Tear Prevention

Elizabeth Ayello and R.Gary Sibbald

Skin Tears - Goals

  1. Prevent skin tears in elderly clients.
  2. Identify clients at risk for skin tears.11
  3. Foster healing of skin tears by
    1. Retaining skin flap
    2. Providing a moist, nonadherent dressing. 12, 13
    3. Protecting the site from further injury
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Skin Tears - Background and Statement of Problem

  1. Traumatic wounds from mechanical injury of skin
  2. Need to clearly differentiate etiology of skin tears from pressure ulcers
  3. Common in the elderly, especially over areas of age-related purpura
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Skin Tears - Parameters of Assessment

  1. Use the three-group risk assessment tool 11 to assess for skin tear risk.(see resources section-IF SG finds this)
  2. 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
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Skin Tears - Nursing Care Strategies and Interventions 15

  1. Preventing Skin Tears
    1. Provide a safe environment:
      1. Do a risk assessment of elderly patients on admission.
      2. Implement prevention protocol for patients identified as at risk for skin tears.
      3. Have patients wear long sleeves or pants to protect their extremities.16
      4. Have adequate light to reduce the risk of bumping into furniture or equipment.
      5. Provide a safe area for wandering.
    2. Educate staff or family caregivers in the correct way of handling patients to prevent skin tears.
    3. Maintain nutrition and hydration:
      1. Offer fluids between meals.
      2. Use lotion, especially on dry skin on arms and legs, twice daily.17
      3. Obtain a dietary consultation.
    4. Protect from self-injury or injury during routine care:
      1. Use a lift sheet to move and turn patients.
      2. Use transfer techniques that prevent friction or shear.
      3. Pad bedrails, wheelchair arms, and leg supports. 16
      4. Support dangling arms and legs with pillows or blankets.
      5. Use nonadherent dressings on frail skin.
        1. 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.
        2. 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.
      6. Use gauze wraps, stockinettes, flexible netting, or other wraps to secure dressings rather than tape.
      7. Use no-rinse soapless bathing products.17, 18
      8. Keep skin from becoming dry, apply moisturizer. 16, 19
  2. Treating Skin Tears 20
    1. Gently clean the skin tear with normal saline.
    2. Let the area air dry or pat dry carefully.
    3. Approximate the skin tear flap.
    4. Use caution if using film dressings because skin damage can occur when removing dressings.
    5. Consider putting an arrow to indicate the direction of the skin tear on the dressing to minimize any further skin injury during dressing removal.
      1. 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.
      2. Always assess the size of the skin tear; consider doing a wound tracing.
      3. Document assessment and treatment findings.
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Skin Tears - Evaluation and Expected Outcomes

  1. No skin tears will occur in at-risk clients.
  2. Skin tears that do occur will heal.
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Skin Tears - Follow-up Monitoring of Condition

  1. Continue to reassess for any new skin tears in older adults.
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For Definition of Levels of Quantitative Evidence Click Here 

References

For definition of Levels of Quantitative Evidence click here.

  1. Cuddigan, J., Ayello, E. A., & Sussman, C. (Eds.) (2001). Pressure ulcers in America: Prevalence, incidence, and implications for the future. Reston, VA: National Pressure Ulcer Advisory Panel. Evidence Level I: Systematic Review/Meta-Analysis.
  2. Health Care Financing Administration (HCFA). (2000, June). Investigative protocol, guidance to surveyors: Long term care facilities (Rev. 274).Washington, DC: U.S. Department of Health and Human Services.
  3. AHCPR. (1992, May). Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, Number 3. AHCPR Publication No. 92-0047. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Level VI: Expert Panel Concensus.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. Centers for Medicare and Medicaid Services (CMS) (2004). Guidance for surveyors in long term care. Tag F 314. Pressure ulcers. Retrieved December 30, 2006, from http://www.cms. hhs.gov/manuals/downloads/som107ap pp guidelines ltcf.pdf. Evidence Level V: Literature Review.
  10. Ayello, E. A., & Braden, B. (2001). Why is pressure ulcer risk so important? Nursing, 31(11), 74-79. Evidence Level V: Review.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. Baranoski, S. (2000). Skin tears: The enemy of frail skin. Advances in Skin and Wound Care, 13(3), 123-126. Evidence Level V: Review.
  16. 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.
  17. 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.
  18. 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.
  19. Hanson, D. H., Anderson, J., Thompson, P., & Langemo, D. (2005). Skin tears in long-term care: Effectiveness on skin care protocols on prevalence. Advances in Skin and Wound Care, 18, 74. Evidence Level III: Quasi-experimental Study.
  20. Baranoski, S., & Ayello, E. A. (2004). Wound care essentials: Practice principles (pp. 54-58 ). Springhouse, PA: Lippincott, Williams, & Wilkins. Evidence Level V: Review.

Last updated - January 2008

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