BACKGROUND AND STATEMENT OF PROBLEM

A.  Pressure injury 2009: Occurrence data reported for 2009 (VanGilder et al., 2009)

1. All U.S. facilities
   • Overall prevalence: 12.3%
   • FA prevalence: 5.0%
   • Prevalence excluding Stage 1: 9.0%
   • FA prevalence excluding Stage 1: 3.2%
2. Acute care

B.  Etiology and/or epidemiology

1. Risk factors (immobility, undernutrition or malnutrition, incontinence, friable skin, impaired cognitive ability)
2. Higher incidence of Stage 2 and higher in persons with darkly pigmented skin

PARAMETERS OF ASSESSMENT

A.  Perform a structured pressure ulcer risk assessment that includes complete skin assessment, consideration of all risk factors, and inclusion of subscores as well as total score when using a valid risk-assessment tool (NPUAP, EPUAP, & PPPIA, 2014).

1. Inspect skin regularly for color changes such as redness in lightly pigmented persons and discoloration in darkly pigmented persons (EPUAP & NPUAP, 2019).
2. Look at the skin located under any medical device (e.g., catheters, oxygen, airway or ventilator tubing, face masks, braces, and collars at least twice daily and more frequently in persons with fluid shifts or localized or generalized edema [NPUAP, EPUAP, & PPPIA, 2014]).
3. Palpate skin for changes in temperature (warmth), edema, or hardness.
4. Ask the patient whether he or she has any areas of pain or discomfort over bony prominences.

B.  Assess for intrinsic and extrinsic risk factors.

C.  Braden Scale risk score—18 or less for older adults and persons with darkly pigmented skin; pay attention to low subscale scores also.

NURSING CARE STRATEGIES AND INTERVENTIONS

A.  Risk-assessment documentation

1. On admission to acute care
2. Reassess at intervals, taking into account the patient’s acuity, any change in condition, and based on patient care setting:
   • Based on patient acuity every 24 to 48 hours on general units
   • Assess critically ill patients every 12 hours
3. Use a reliable and standardized tool as part of a risk assessment, such as the Braden Scale, as part of a comprehensive risk assessment (available at http://www.bradenscale.com/images/bradenscale.pdf). Do not rely only on a standardized tool for risk assessment!
4. Document risk-assessment scores and implement prevention protocols based on overall scores, low subscores, and the comprehensive assessment of other risk factors.
5. Assess risk of surgical patients for increased risk of PI, including the following factors: length of operation, number of hypotensive episodes, and/or low-core temperatures intraoperatively, as well as reduced mobility on first day postoperatively.

B.  General care issues and interventions

1. Culturally sensitive early assessment for Stage 1 PI in patients 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, warmer or cooler.
2. Prevention recommendations:
   • Skin care (NPUAP, EPUAP, & PPPIA, 2014
     • i.  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 injury prevention strategy; do not vigorously rub skin at risk for PI.
     • 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 and shear during transferring and turning of patients. 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 away from the skin.
     • Consider protecting high-risk areas, such as elbows, heels, and sacrum, prophylactically from friction injury using foam dressing (NPUAP, EPUAP, & PPPIA, 2014).
   • Repositioning and support surfaces
     • Assess skin and other patient characteristics, as well as pressure injury risk, and consider using the WOCN evidence and consensus-based support surface algorithm (McNichol et al., 2015).
     • Keep patients off the reddened areas of skin.
     • Repositioning schedules should be individualized on the basis of the patient’s condition, care goals, vulnerable skin areas, and type of support surface being used (NPUAP, EPUAP, & PPPIA, 2014).
     • Communicate the repositioning schedule to all the patient’s caregivers.
     • Raise heels of bedbound patients off the bed using either pillows or heel-protection devices; do not use donut-type devices (Gilcreast et al., 2005).
     • Use a 30° tilted, side-lying position; do not place patients directly in a 90° 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 patients rather than dragging them in bed during transfers and position changes.
     • Use pressure-reducing devices (static air, alternating air, gel, or water mattresses; Hampton & Collins, 2005; Iglesias et al., 2006). Use higher specification foam mattresses rather than standard hospital mattress for patients at risk for PI. If the patient cannot be frequently repositioned manually, use an active support surface (overlay or mattress).
     • Use high-specification reactive or alternating pressure support surfaces on the operating table for patients identified at risk for developing PI. Additional support surfaces, such as facial pads, are needed for patients in the prone position (NPUAP, EPUAP, & PPPIA, 2014).
     • Reposition chair-bound or wheelchair-bound patients every hour. In addition, if patient is capable, have him or her do small weight shifts every 15 minutes.
     • Use a pressure-reducing device (not a donut) for chair-bound patients.
     • 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.
     • Keep heels off the bed using heel suspension devices or other equipment that also avoids placing pressure on the Achilles tendon (NPUAP, EPUAP, & PPPIA, 2014).
     • Manage friction and shear:
       • Elevate the head of the bed no more than 30°.
       • Have the patient use a trapeze or other transfer devices to lift self up in bed.
       •  Staff should use transfer devices, a lift sheet, or mechanical lifting device to move patient.
   • Nutrition
     • Assess nutritional status of patients at risk for PI.
     • Assess and monitor weight status (NPUAP, EPUAP, & PPPIA, 2014).
     • For at-risk patient, follow nutritional guidelines for hydration (1 mL/kcal of fluid/d), calories (30–35 kcal/kg of body weight/d), and protein (1.25–1.5 g/kg/d). Give high-protein supplements or tube feedings in addition to the usual diet in persons at nutritional and pressure ulcer risk (NPUAP, EPUAP, & PPPIA, 2014; Posthauer et al., 2015).
     • 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 with turning schedules to keep patient hydrated.

C.  Interventions linked to Braden risk scores (Ayello & Braden, 2001)

Prevention protocols linked to Braden risk scores are as follows:

1. At risk: score of 15 to 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 chair bound.
2. Moderate risk: score of 13 to 14
   • Same as cited, but provide foam wedges for 30° lateral position.
3. High risk: score of 10 to 12
   • Same as cited, but add the following (b and c).
   • Increase the turning frequency.
   • Do small shifts of position.
4. Very high risk: score of 9 or less
   • Same as cited but use a pressure-relieving surface.
   • Manage moisture, nutrition, and friction and shear.

EVALUATION AND EXPECTED OUTCOMES

A.  Patient:

1. Skin will remain intact.
2. Pressure ulcer will heal.

B.  Provider or nurse will:

1. Accurately perform PI risk assessment using standardized tool.
2. Implement PU prevention protocols for patients interpreted as at risk for PI.
3. Perform a skin assessment for early detection of PI.

C.  Institution will:

1. Reduce development of new PI.
2. Increase number of risk assessments performed.
3. Develop cost-effective prevention protocols.

FOLLOW-UP MONITORING OF CONDITION

A.  Monitor effectiveness of prevention interventions.

B.  Monitor healing of any existing PU.

ABBREVIATIONS

EPUAP       European Pressure Ulcer Advisory Panel

FA               Facility acquired

NPUAP       National Pressure Ulcer Advisory Panel

PI                 Pressure injury

PPPIA         Pan Pacific Pressure Injury Alliance

PU               Pressure ulcer

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 28: Persaud-Jaimangal, R., Ayello, E., & Sibbald, G. (2021) Preventing Pressure Injuries and Skin Tears.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 501-525).   New York: Springer.