Pressure Sores; Pressure Ulcers; Bed Sores; Decubitus Care
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Risk Control
* Risk Detection
* Tissue Integrity: Skin and Mucous Membranes
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Pressure Ulcer Prevention
* Skin Surveillance
NANDA Definition: At risk for skin being adversely altered
Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses, and other devices. Preventive measures are usually not reimbursable, even though costs related to treatment once breakdown occurs are greater.
* Risk Factors: Extremes of age
* Poor nutrition
* Mechanical forces (e.g., pressure, shear, friction)
* Pronounced bony prominences
* Poor circulation
* Altered sensation
* Environmental moisture
* History of radiation
* Hyperthermia or hypothermia
* Acquired immunodeficiency syndrome (AIDS)
* Expected Outcomes Patient’s skin remains intact, as evidenced by no redness over bony prominences and capillary refill less than 6 seconds over areas of redness.
* Determine age. Elderly patients’ skin is normally less elastic and has less moisture, making for higher risk of skin impairment.
* Assess general condition of skin. Healthy skin varies from individual to individual, but should have good turgor (an indication of moisture), feel warm and dry to the touch, be free of impairment (scratches, bruises, excoriation, rashes), and have quick capillary refill (<6 seconds).
* Specifically assess skin over bony prominences (e.g., sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of head). Areas where skin is stretched tautly over bony prominences are at higher risk for breakdown because the possibility of ischemia to skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone.
* Assess patient’s awareness of the sensation of pressure. Normally, individuals shift their weight off pressure areas every few minutes; this occurs more or less automatically, even during sleep. Patients with decreased sensation are unaware of unpleasant stimuli (pressure) and do not shift weight. This results in prolonged pressure on skin capillaries, and ultimately, skin ischemia.
* Assess patient’s ability to move (e.g., shift weight while sitting, turn over in bed, move from bed to chair). Immobility is the greatest risk factor in skin breakdown.
* Assess patient’s nutritional status, including weight, weight loss, and serum albumin levels. An albumin level less than 2.5 g/dl is a grave sign, indicating severe protein depletion. Research has shown that patients whose serum albumin is less than 2.5 g/dl are at high risk for skin breakdown, all other factors being equal.
* Assess for edema. Skin stretched tautly over edematous tissue is at risk for impairment.
* Assess for history of radiation therapy. Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown.
* Assess for history or presence of AIDS. Early manifestations of HIV-related diseases may include skin lesions (e.g., Kaposi’s sarcoma); additionally, because of their immunocompromise, patients with AIDS often have skin breakdown.
* Assess for fecal and/or urinary incontinence. The urea in urine turns into ammonia within minutes and is caustic to the skin. Stool may contain enzymes that cause skin breakdown. Use of diapers and incontinence pads with plastic liners traps moisture and hastens breakdown.
* Assess for environmental moisture (e.g., wound drainage, high humidity). Moisture may contribute to skin maceration.
* Assess surface that patient spends majority of time on (e.g., mattress for bedridden patient, cushion for persons in wheelchairs). Patients who spend the majority of time on one surface need a pressure reduction or pressure relief device to distribute pressure more evenly and lessen the risk for breakdown.
* Assess amount of shear (pressure exerted laterally) and friction (rubbing) on patient’s skin. A common cause of shear is elevating the head of the patient’s bed: the body’s weight is shifted downward onto the patient’s sacrum. Common causes of friction include the patient rubbing heels or elbows against bed linen, and moving the patient up in bed without the use of a lift sheet.
* Reassess skin often and whenever the patient’s condition or treatment plan results in an increased number of risk factors. The incidence and onset of skin breakdown is directly related to the number of risk factors present.
* If patient is restricted to bed:
o Encourage implementation and posting of a turning schedule, restricting time in one position to 2 hours or less and customizing the schedule to patient’s routine and caregiver’s needs. A schedule that does not interfere with the patient’s and caregivers’ activities is most likely to be followed.
* Encourage implementation of pressure-relieving devices commensurate with degree of risk for skin impairment:
o For low-risk patients: good-quality (dense, at least 5 inches thick) foam mattress overlay Egg crate mattresses less than 4 to 5 inches thick do not relieve pressure; because they are made of foam, moisture can be trapped. A false sense of security with the use of these mattresses can delay initiation of devices useful in relieving pressure.
o For moderate risk patients: water mattress, static or dynamic air mattress In the home, a waterbed is a good alternative.
o For high-risk patients or those with existing stage III or IV pressure sores (or with stage II pressure sores and multiple risk factors): low-air-loss beds (Mediscus, Flexicare, Kinair) or air-fluidized therapy (Clinitron, Skytron) Low-air-loss beds are constructed to allow elevated head of bed (HOB) and patient transfer. These should be used when pulmonary concerns necessitate elevating HOB or when getting patient up is feasible. "Air-fluidized" therapy supports patient’s weight at well below capillary closing pressure but restricts getting patient out of bed easily.
* Encourage patient and/or caregiver to maintain functional body alignment.
* Limit chair sitting to 2 hours at any one time. Pressure over sacrum may exceed 100 mm Hg pressure during sitting. The pressure necessary to close skin capillaries is around 32 mm Hg; any pressure greater than 32 mm Hg results in skin ischemia.
* Encourage ambulation if patient is able.
* Increase tissue perfusion by massaging around affected area. Massaging reddened area may damage skin further.
* Clean, dry, and moisturize skin, especially over bony prominences, twice daily or as indicated by incontinence or sweating. If powder is desirable, use medical-grade cornstarch; avoid talc.
* Encourage adequate nutrition and hydration:
o 2000 to 3000 kcal/day (more if increased metabolic demands).
o Fluid intake of 2000 ml/day unless medically restricted. Hydrated skin is less prone to breakdown. Patients with limited cardiovascular reserve may not be able to tolerate this much fluid.
* Encourage use of lift sheets to move patient in bed and discourage patient or caregiver from elevating HOB repeatedly. These measures reduce shearing forces on the skin.
* Leave blisters intact by wrapping in gauze, or applying a hydrocolloid (Duoderm, Sween-Appeal) or a vapor-permeable membrane dressing (Op-Site, Tegaderm). Blisters are sterile natural dressings. Leaving them intact maintains the skin’s natural function as barrier to pathogens while the impaired area below the blister heals.
Education/Continuity of Care
* Consult dietitian as appropriate.
* Teach patient and caregiver the cause(s) of pressure ulcer development:
o Pressure on skin, especially over bony prominences
o Poor nutrition
o Shearing or friction against skin
* Reinforce the importance of mobility, turning, or ambulation in prevention of pressure ulcers.
* Teach patient or caregiver the proper use and maintenance of pressure-relieving devices to be used at home.