Which of the following interventions is best to decrease a clients risk for skin breakdown?

Most pressure injuries and skin tears can be prevented by following simple steps such as maintaining good nutrition and hydration, regular but careful mobilisation, good skin hygiene and a good moisturising regime.

Prevention plan

We can use the results of the risk screen or assessment to develop and implement a prevention plan1. We should then monitor the plan.

The following prevention strategies may be included in a plan to reduce the risk of skin damage.

Positioning

Being immobile or staying in one position for a length of time can increase our risk of developing pressure injuries.

• To relieve pressure, patients should change position regularly, whether they are in a bed or a chair. If the patient is unable to reposition themselves, they are at high risk and need repositioning every two hours.
• For patients in bed, a 30 degree tilt to either side is enough to reduce pressure. We can use ‘side to side’ nursing, which involves alternating the patient’s position from one side, to their back, and then to the other side.
• The frequency of repositioning depends on the following factors:
  • risk of developing a pressure injury and skin condition
  • tissue tolerance
  • level of activity and mobility
  • general medical condition
  • overall treatment objectives
  • support surface used
  • comfort2,3.
• Encourage patients to change their position as often as necessary to reduce the risk of developing pressure injuries.
• Use transfer assistance devices to promote independent transferring.

Environment

The environment can increase a person’s risk of injuring their skin.

• Keep the environment free of clutter, well-lit, well signed and easy to navigate. This will help avoid a collision with environmental hazards such as bed rails, lifting machines parts and wheelchair footplates.
• Orient the person to the environment to minimise injury, confusion and disorientation.
• Provide adequate lighting.

Protective relieving devices

• Provide patients with equipment to prevent damage to the skin, including:
  • protective mattresses or bed support surfaces
  • seat cushions and support surfaces
  • heel wedges or support - heel protection devices should elevate the heel completely and distribute the weight of the leg along the calf without placing undue pressure on the Achilles tendon.3, 4

“Disposable, single patient devices, such as positional foams, which are utilised within one area of the hospital could be part of the patient’s package of care and travel with them throughout the various departments of any care setting”5

• Refer to an occupational therapist for specialised advice.
• Note that sheepskins and water filled gloves are not considered pressure relieving devices.

Protective clothing

Encourage the patient to wear protective clothing to reduce the risk of skin tears, such as:

• long sleeves
• long trousers
• knee-high socks
• shin and elbow guard pads
• appropriate footwear.

Nutrition

Good nutrition plays a key role in maintaining good skin. Under-nourished and dehydrated people do not have sufficient nutrients available to maintain good skin health6.

Use a valid and reliable nutrition screening tool to determine the nutritional status of patients at risk of or with a pressure injury3.

Skin moisture

Exposure to urine and faeces is one of the most common causes of skin breakdown and makes the skin more susceptible to injury.

• If required, develop and implement an individualised continence management plan in partnership with the patient, their family and carer and interdisciplinary healthcare team as appropriate3. This is particularly important to keep the patient’s skin dry overnight without disturbing them.
• Refer to a continence specialist if necessary.
• If a patient perspires a lot, they may benefit from more frequent skin washing, especially in skin folds.
• Regularly change a patient’s clothes and bed linen if they become moist. Cotton sheets are best as moisture can evaporate more quickly.
• Avoid using plastic or rubber chair or mattress protectors. These are more likely to make patients sweat.

Skin cleansing and skin care

As the skin ages it can become very fragile.

• Use warm water instead of hot water when washing.
• Use soap alternatives to reduce the drying effects of soap, for example, emollient soap substitute or skin cleanser.
• Dry the skin thoroughly but gently, using light patting. Do not rub the skin as this may lead to further damage.
• Apply pH neutral moisturiser at least twice daily. Application should follow the direction of the body hair and be gently smoothed into the skin. Evidence shows that the twice-daily application of moisturiser morning and night can reduce skin tears by almost 50 per cent. Moisturisers come in a lotion, cream and ointment. Assess which moisturiser is appropriate for a patient’s skin type.
• Keep frail skin on limbs moisturised and covered for protection.
• Keep the patient’s fingernails and toenails suitably trimmed.
• Use non-adherent and non-adhesive dressings.

Balance and mobility

Older people should be encouraged to mobilise regularly during their hospital stay to minimise the risk of functional decline. However, we need to be aware that using mobility aids can increase a patient’s risk of skin damage through wheelchair injuries, falls, transfers or blunt trauma from bumping into objects.

• Conduct a falls risk assessment and if necessary implement a falls prevention program.
• Use padding on mobility aids to reduce the risk of injury.
• Refer to a physiotherapist if there appears to be balance and mobility problems.

Medication management

Certain medications can affect a patient’s skin.

• The following medications can cause various types of cutaneous or inflammatory interactions/reactions:
  • antibacterials
  • antihypertensives
  • analgesics
  • tricyclic antidepressants
  • antihistamines
  • antineoplastic drugs
  • antipsychotic drugs
  • diuretics
  • oral diabetes agents
  • nonsteroidal anti-inflammatory drugs
  • steroids
• Refer to a doctor or pharmacist for a review of medications if there is concern that the patients’ medications are affecting their skin.

Documentation

Document prevention strategies in the patient’s clinical notes and communicate these strategies during clinical handover and on transfer or discharge.

Monitoring and evaluation

Monitor and evaluate the prevention plan and strategies for their effectiveness. Modify the strategies and interventions, in consultation with the patient and treating team as necessary.

1. Australian Commission on Safety and Quality in Healthcare (ACSQHC), National Safety and Quality Health Service Standards, 2011, ACSQHC: Sydney.

2. Department of Health, Preventing and Managing Pressure Injuries, 2014, Sector Performance, Quality and Rural Health, Victorian Governement, Department of Health.

3. 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, 2014: Perth, Australia.

4. Australian Wound Management Association, Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, 2012: Cambridge Media Osborne Park, WA.

5. Bateman, S.D., Pressure ulcer prevention in the seated patient: Adopting theatre practices to protect skin integrity. Wounds UK, 2013. 9(3): p. 71-75.

6. Acton, C., The importance of nutrition in wound healing. Wounds UK, 2013. 9(3): p. 61-64.

What are interventions to prevent skin breakdown?

What nursing interventions prevent skin breakdown?

Which intervention by the nurse reduces the risk of skin breakdown while moving the client up in the bed?

What are 3 appropriate prevention strategies for maintaining skin integrity and pressure area care for this client?