Skin Integrity, Impaired: Risk For - Pressure Sores; Pressure
Ulcers, Bed Sores; Decubitus Care
Audrey Klopp, RN, PhD,
ET, CS, NHA
Virginia M. Storey, RN, ET
Kathryn S. Bronstein, RN, PhD,
NANDA: The state in which an individual's skin is at risk of
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; and 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.
- Extremes of age
- Poor nutrition
- Mechanical forces (pressure, shear, friction)
- Pronounced bony prominences
- Poor circulation
- Altered sensation
- Environmental moisture
- History of radiation
- Hyperthermia or hypothermia
- Acquired immunodeficiency syndrome (AIDS)
Patient's skin remains intact, as evidenced by no redness over
bony prominences and capillary refill <6 seconds over areas of redness.
- (i) independent
- (i) Determine age.
- Elderly patients' skin is normally less elastic and has
less moisture, making for higher risk of skin impairment.
- (i) 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 (less than 6 seconds).
- (i) Specifically assess skin over bony
prominences (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
(mattress, chair, or table) and the bone.
- (i) 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.
- (i) Assess patient's ability to move (shift
weight while sitting, turn over in bed, move from bed to chair).
- Immobility is the greatest risk factor in skin
- (i) Assess patient's nutritional status,
including weight, weight loss, and serum albumin levels.
- An albumin level greater than 2.5 g/100 ml is a grave sign,
indicating severe protein depletion. Research has shown that patients whose
serum albumin is greater than 2.5 g/100 ml are at high risk for skin breakdown,
all other factors being equal.
- (i) Assess for edema.
- Skin stretched tautly over edematous tissue is at risk for
- (i) Assess for history of radiation
- Radiated skin becomes thin and friable, may have less blood
supply, and is at higher risk for breakdown.
- (i) Assess for history or presence of
- 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.
- (i) Assess for fecal and/or urinary
- 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 trap moisture and hasten
- (i) Assess for environmental moisture (wound
drainage, high humidity).
- That may contribute to skin maceration.
- (i) Assess surface that patient spends
majority of time on (mattress for bedridden patient, cushion for persons in
- 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.
- (i) 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
- (i) Reassess skin often and whenever the
patient's condition or treatment plan results in an increased number of risk
- The incidence and onset of skin breakdown is directly
related to the number of risk factors present.
- (i) independent
- (i) If patient is restricted to bed:
- 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.
- (c) Encourage implementation of
pressure-relieving devices commensurate with degree of risk for skin
- For low-risk patients: good-quality (dense, at least 5 inches
thick) foam mattress overlay.
- Eggcrate 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.
- For moderate risk patients: water mattress, static or dynamic
- In the home, a water bed is a good
- 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
- 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.
- (i) Encourage patient and/or caregiver to
maintain functional body alignment.
- (i) Limit chair sitting to 2 hours at any one
- 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.
- (i) Encourage ambulation if patient is
- (i) Increase tissue perfusion by massaging
around affected area.
- Massaging reddened area may damage skin further.
- (i) 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
- To reduce friction.
- (c) Encourage adequate nutrition and
- 2000 to 3000 calories per day (more if increased metabolic
- Fluid intake of 2000 ml per day unless medically restricted.
- Hydrated skin is less prone to breakdown. Patients with
limited cardiovascular reserve may not be able to tolerate this much
- (i) Encourage use of lift sheets to move
patient in bed and discourage patient or caregiver from elevating HOB
- These measures reduce shearing forces on the
- (c) 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
- (i) independent
- (c) Consult dietitian as appropriate.
- (i) Teach patient and caregiver the cause(s)
of pressure ulcer development:
- Pressure on skin, especially over bony prominences
- Poor nutrition
- Shearing or friction against skin
- (i) Reinforce the importance of mobility,
turning, or ambulation in prevention of pressure ulcers.
- (i) Teach patient or caregiver the proper use
and maintenance of pressure-relieving devices to be used at home.
Pressure Ulcer Prevention; Skin Surveillance
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