Pressure Ulcer Prevention and Skin Assessment
Category: Skin Care
Overview
Systematic skin assessment and implementation of pressure ulcer prevention strategies for at-risk patients.
Indications
Immobility, prolonged bed rest, poor nutrition, advanced age, incontinence, sensory impairment, chronic illness, post-operative patients.
Contraindications
None - assessment is appropriate for all patients. Interventions may be modified based on patient condition.
Equipment Needed
Good lighting, measuring device, pressure-relieving devices, moisturizers, barrier creams, repositioning schedule, documentation materials.
Procedure Steps
1. Perform comprehensive skin assessment on admission
2. Identify high-risk pressure points: heels, sacrum, hips, shoulders, elbows
3. Assess for existing pressure injuries and stage appropriately
4. Implement turning schedule (every 2 hours minimum)
5. Use pressure-relieving surfaces and devices
6. Keep skin clean and dry
7. Apply moisturizer to dry areas
8. Protect bony prominences with padding
9. Maintain adequate nutrition and hydration
10. Educate patient and family on prevention
11. Document skin condition and interventions
12. Reassess skin every shift and PRN
Safety Considerations
Use proper lifting and turning techniques. Avoid dragging or friction. Keep linens clean and wrinkle-free. Monitor for signs of infection in existing wounds.
Potential Complications
Pressure ulcer development, skin breakdown, infection, delayed healing, pain, decreased mobility.
Documentation
Record location, size, and stage of any pressure injuries, skin condition, prevention measures implemented, turning schedule compliance, and patient/family education.
References
National Pressure Injury Advisory Panel. (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Wound, Ostomy and Continence Nurses Society Guidelines.