Those working with at-risk populations must be aware of how to address the skin care needs of our patients and prevent pressure ulcers and injuries. At-risk populations, such as older adults, persons who are incontinent, pediatric patients, immobile patients, post-operative patients, and those with chronic disease processes and spinal injuries, for example, are most at risk for developing pressure ulcers. Those patients who have comorbidities such as obesity, diabetes, and cardiovascular disease are at additional risk.

Pressure ulcers are a key concern in health care and have a variety of contributing factors. It is essential that caregivers are aware of how pressure ulcers occur, as well as how to manage the skin of persons at risk of developing these ulcers. This blog covers skin management of patients at risk, assessment guidelines, and therapeutic interventions.

It is important to know that in persons at very high risk, such as a recent motor vehicle accident victim who is on vasopressors in the intensive care unit, skin complications may be inevitable. In these situations, caregivers must choose what the priority is, and occasionally skin integrity is of less importance than the patient’s spinal alignment or cardiac output. These patients may be moved less often, and sometimes only out of necessity, until they are cleared by a computed tomography scan and can handle changes in movement without aggravating or causing strain on the heart.

There are those who are at the end of life, and these patients should be evaluated using the SCALE system.

Guidelines for the Regular Risk Assessment

Although there are a few guidelines available, such as the Norton Scale and the Braden Scale for Predicting Pressure Sore Risk (Braden Scale), in most facilities you will find the Braden Scale commonly used. Using the assessment tool is important for consistency among staff. Yet, it has been proven that the use of the scale is beneficial only if it is paired with the prevention techniques outlined by the National Pressure Ulcer Advisory Panel (NPUAP) and Wound, Ostomy and Continence Nurses Society (WOCN).

Assessment should be completed on all admitted patients, during every shift (every eight hours is recommended), and with any changes in mobility or medical conditions. The Braden Scale includes evaluation of sensory perception, moisture, activity, mobility, nutrition, and friction, with a higher score indicating a lower risk.

Particular areas of attention are evaluation of skin temperature, color, moisture level, turgor, and integrity of the area, which includes open areas and intact skin. The assessment should be all inclusive, from head to toe. Anatomic structures and medical devices to consider in the assessment are bony prominences, including the often missed occiput and elbows, the sacral and perineal area, oxygen tubing, and the back of the head for infants. Essentially, any area that touches the bed, tubes, or equipment should be evaluated for pressure.

Therapeutic Interventions for Preventing Skin Complications

There are many techniques that have proven to be best practices over time. Organizations such as the NPUAP and WOCN have published guidelines on how to prevent skin breakdown in patients who are compromised. Prevention of pressure ulcers includes many interventions, including but not limited, to:

• Eliminating sweat, urine, and stool from contacting the skin
• Considering gel or air mattresses for those at higher risk
• Padding bony prominences with devices or preventative dressings such as foam
• Using pressure distribution mattresses that reduce the impact on bony prominences
• Providing nutritional therapy, enteral or parenteral feeding, and hydration supplementation
• Minimizing use of briefs in incontinent patients because briefs can hold moisture to the skin
• Repositioning the patient often, at least every 1–2 hours
• Turning a patient just 30 degrees from side to side, which can offload that pressure gradient just enough when turning every 1–2 hours
• Lifting the patient, not dragging the patient with the draw sheet or pad, when boosting or repositioning because dragging can cause skin breakdown by shear force
• Ensuring that tubes, drains, and device cords are not under the patient or pressing hard to the skin
• Tilting wheelchairs at 30 degrees to lessen the impact on the sacral area
• Keeping the overall skin clean and dry
• Minimizing of layers under the patient
• If the patient is not able to verbalize their needs, using non-verbal cues from the patient such as hand gestures, grimacing, or other indicators or skin color and temperature changes
• Using offloading devices, such as foam positioners or air boots for the heels, which can minimize pressure on bony prominences prone to breakdown

Dilligence in preventing skin care–related conditions, such as incontinence-associated dermatitis and pressure ulcers, is an important component of the patient’s care plan. All members of the health care team should be educated and kept accountable for their actions in preventing these occurrences. Documenting changes and the time of assessment and possibly taking secure photographs for the electronic medical record are important in the chronological order of documentation. Being aware of best practices for managing those patients at risk for skin breakdown is the responsibly of all caregivers.

Suggested Reading
Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2014.
Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers (Injuries). WOCN Clinical Practice Guideline Series 2. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2016.