There has been extensive research on how to prevent skin care-related skin breakdown, and most research agrees on a few main components. Eliminating skin contact with sweat, urine, and stool reduces the risk of maceration and incontinence-associated dermatitis and thereby helps to prevent or minimize skin breakdown. Proper mattress selection and offloading devices are important for minimizing the impact of weight on bony prominences. Nutritional therapy is also a key component of maintaining skin integrity. This is because this therapy supplies nutrients that the body requires, as well as hydration. Turning, repositioning, and avoiding the impact of shear force when adjusting the patient are important to eliminate mechanical forces that can break down the tissue. Most importantly, having a consistent method to assess skin integrity and using a validated scale such as the Braden Scale for Predicting Pressure Sore Risk® (Braden Scale) are the most effective methods of tracking changes and implementing the necessary interventions based on the area or areas of deficiency.

Holistic Approach to Assessment and Skin Breakdown Prevention

It is important to have a holistic approach to prevention of skin breakdown and to implement strategies that take into consideration the entire person. For example, if you have a frail, low-income, 89-year-old patient with diabetes who is hospitalized after a fall and has an unstable hip fracture, you must look at the whole picture. Let us use this example and discuss the best ways to avoid skin breakdown. Taking this example, you can see that the assessment of the skin is going to be important because of this patient’s comorbidities. His sensory perception is impaired by both his diabetes and the hip fracture. His ability to respond to pressure-related pain may be masked by nerve deficiencies.

It is also possible that he may have some moisture issues because he is immobilized with an unstable hip fracture. He could have some baseline incontinence, or this could be a new situation for him. His activity and mobility are severely affected by the unstable fracture. His nutritional risk could vary based on his intake and blood glucose control at home. It would be prudent to check his hemoglobin A1c and a pre-albumin level. The next consideration is whether he will be NPO (taking nothing by mouth) in preparation for going to the operating room. Skin assessments are to be done on admission and during every shift, preferably every eight hours, and with any medical changes. Managing comorbidities and looking at the whole picture are important to developing the correct plan of care for the patient. Of the considerations discussed here, one that is most often underprioritized is the area of nutrition and hydration.

The National Pressure Ulcer Advisory Panel (NPUAP) recommends that patients with pressure ulcers maintain a protein intake of 1.25–1.5g per kg of body weight per day. If the nutritional demand is not met, it could result in prolonged healing or worsening of the pressure ulcer stage. In patients with reduced nutritional intake, particularly protein intake, studies have shown a reduced collagen foundation in the wound and increased wound dehiscence. Another often overlooked issue is wound exudate. If the wound has a large amount of output, such as in a patient using a vacuum-assisted closure therapy device, the patient can lose 100g of protein daily based on the high quantity of exudate. Not only is it best practice to evaluate the skin in a holistic manner, but also it is becoming more important for financial reasons. As a result of reimbursement changes, practitioners and clinicians need to be more fully educated on pressure ulcers and make prevention a priority.

Education on Skin Care and Prevention for the Patient and Caregiver

Skin care and pressure ulcers can be difficult for the patient’s loved ones to discuss, especially if it is a new wound or in a private area such as the sacral area. Many patients and family members do not know how to cope with a pressure ulcer and feel embarrassed or nervous on seeing the wound. When educating caregivers, remember that this is their loved one, and it is not a clinical moment for them. This is their wife or mother, and they are scared of hurting them, causing embarrassment, making the wound worse, or causing an infection. It is important to discuss pain, dressing care, and prevention strategies. Yet, most of all, when talking to caregivers, please give them room to be human and voice their current knowledge and their concerns. Do not use canned answers—customize your responses to the individual’s needs.

Suggested Reading

Guy H. Pressure ulcer risk assessment. Nurs Times. 2012;108(4):16, 18–20. Haesler E, ed. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2014. Pressure ulcer prevention: a shared inter-professional responsibility. W CET J. 2018;38(4):18–27.