Skin breakdown is medically termed a pressure injury, also known as a pressure ulcer. This localized damage to the skin and underlying soft tissue typically occurs over bony prominences due to sustained pressure, or pressure combined with shear and friction. Prevention is a primary responsibility for nursing staff, as these wounds are associated with poor patient outcomes, including increased infection risk and mortality. Furthermore, treating pressure injuries is a significant financial burden, costing the United States healthcare system an estimated $9.1 to $11.6 billion annually.
Assessing Patient Risk Factors
The first step in prevention is a systematic assessment of a patient’s risk profile to ensure interventions are individualized. Nurses commonly use the Braden Scale for this purpose, a validated tool that quantifies a patient’s risk of developing a pressure injury. This scale is composed of six sub-scales that evaluate different contributing factors to skin breakdown. The individual scores from these categories are summed to determine a total risk score. This assessment is not merely a numerical exercise but a prompt for action.
The six sub-scales are:
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
A low score in any single sub-scale, such as severely limited Mobility, can trigger specific interventions even if the total score suggests a moderate risk. The assessment prompts nursing staff to analyze the specific physiological and environmental deficits of the patient. Targeting the identified area of risk allows nurses to allocate resources efficiently for personalized prevention.
Protocols for Pressure Redistribution and Mobility
Once a patient is identified as being at risk, mechanical interventions focus on reducing the duration and intensity of pressure on vulnerable areas. The foundation of pressure redistribution is a personalized turning schedule, typically involving repositioning immobile patients at least every two hours. The schedule must be adjusted based on the patient’s assessed risk, the support surface used, and the skin’s tolerance to pressure.
A highly effective technique for repositioning is the 30-degree lateral position, which tilts the patient slightly to one side using pillows or foam wedges. This specific angle offloads the body’s major bony prominences, such as the sacrum and greater trochanters, placing the weight onto the fleshy areas of the buttocks and back. Proper alignment requires using supportive devices between the knees to ensure the patient is not resting directly on their hip bone.
Heel offloading is another specific intervention, as the heels are highly susceptible to pressure damage due to their small surface area. Nurses “float” the heels by placing pillows or specialized boots under the calves to suspend the heels completely off the bed surface. This prevents prolonged pressure on the calcaneus, which can rapidly lead to tissue ischemia.
Specialized support surfaces are selected as an adjunct to manual repositioning to manage localized pressure. An alternating pressure mattress features air cells that cyclically inflate and deflate, which constantly shifts the pressure points on the body to improve circulation. Another element is the low air loss mattress, which focuses on microclimate control by circulating air through the mattress surface to keep the patient’s skin cool and dry, minimizing heat and moisture buildup.
Minimizing shear force is equally important during all transfers and repositioning. Shear occurs when skin remains stationary while underlying tissue moves. Nurses reduce this damaging force by using friction-reducing devices, such as draw sheets or slide sheets, to lift and move the patient rather than dragging them. When the head of the bed must be elevated, it should be kept at or below a 30-degree angle for prolonged periods to avoid downward sliding and resulting shear on the sacrum.
Strategies for Moisture and Friction Control
Maintaining the optimal external skin environment involves meticulous hygiene and the application of protective products. Incontinence management is a challenge, as prolonged exposure to urine and feces can lead to moisture-associated skin damage and compromise the skin’s barrier function. Nurses should use pH-balanced, no-rinse skin cleansers instead of harsh soaps and water, which can disrupt the skin’s natural acidic mantle.
To protect the skin from excessive moisture, nurses apply moisture barrier creams, ointments, or films to the perineum and surrounding at-risk areas. Barrier creams typically contain ingredients like zinc oxide or dimethicone and are applied in a thin layer to create a shield against irritants. Care must be taken to apply them gently to avoid dragging fragile skin.
Prophylactic dressings are used to reduce the mechanical forces of friction and shear on high-risk bony areas. Multi-layered soft silicone foam dressings are often applied to the sacrum and heels of patients at high risk for pressure injury development. These dressings absorb mechanical stress and provide an extra layer of cushioning over the bony prominence. The dressings are checked daily and replaced if soiled or no longer intact.
Nutritional and Hydration Support
Internal factors, specifically nutrition and hydration, are fundamental to maintaining the skin’s resilience against external forces. Adequate fluid intake is necessary to ensure proper skin turgor and support tissue perfusion, which delivers oxygen and nutrients to the skin cells. Nurses monitor fluid intake closely, as dehydration can compromise cell metabolism and accelerate the risk of skin breakdown.
Sufficient calorie intake is required to support tissue repair and prevent the body from breaking down its own muscle and tissue for energy. Protein is an important macronutrient for skin health, providing the amino acids necessary for tissue repair and the maintenance of structural proteins. Nurses often work with dietitians to ensure patients receive energy-dense, protein-rich diets to optimize this preventative support.
Micronutrients also play a preventative role in maintaining skin integrity at the cellular level. Vitamin C is required as a cofactor for collagen synthesis, the protein that provides the skin with its strength and elasticity. The mineral Zinc supports cell regeneration and is involved in various enzyme systems that help maintain the skin’s barrier function.