SKIN CARE: PRESSURE INJURY PREVENTION Clinical Protocol

Clinical Protocol: SKIN CARE: PRESSURE INJURY PREVENTION

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SKIN CARE: PRESSURE INJURY PREVENTION

Clinical Protocol

Approved: March 2020 Next Review: March 2023

Clinical Area: All inpatient clinical and emergency department areas

Population Covered: All Adult and Pediatric Inpatients and Emergency Department patients

Campus: Ballard, Cherry Hill, Edmonds, First Hill,

Issaquah, Mill Creek, Redmond Implementation Date: January 2002

Related Procedures, Protocols, and Job Aids: Camera Photography, Video and Audio Recording

Sacral Dressing Application for Pressure Ulcer Prevention

Vacuum Assisted Wound Closure (VAC) Therapy Management

Wound Management: Complex

Using Digital Photography for Patient Care (Haiku Photo Capture)

Perineal Skin Care/Diaper Dermatitis Management Guideline for Neonates and Diapered Children

Skin Injury Prevention Related to Respiratory Therapy

Go directly to: Patient Assessment

Basic Skin Care / Pressure Ulcer Bundle

Skin and Wound Treatment

Braden Scoring

Definitions

Moisture Associated Skin Damage (MASD)

Nail Care

Skin Tears

Pressure Injury Debrief and Handoff

Purpose

To provide guidelines for assessment, prevention, and interventions of common skin-related issues.

Policy Statement

None.

LIP Order Requirement

Elements of this protocol require a licensed independent practitioner’s (LIP) order.

Responsible Persons

RN, LIP, Nursing Assistants (NA-C), Wound Ostomy Nurse (WON)

http://fhscms-ps01/Stellent/groups/standards/documents/swedstd/swed_008061.pdf



http://intracm.swedish.org/Stellent/groups/standards/documents/swedstd/swed_006920.pdf





http://swedishonline.swedish.org/Departments/QT/QualityDivision/Documents/Pressure Injury Debrief Handoff v9_ 3 31 17.pdf



Prerequisite Information

Identification of the patient who is at risk for the development of pressure injury is essential to the success of any

skin care program. Risk factors including immobility, pressure, friction, shear, nutritional deficit, sensory deficit,

inactivity, dehydration, edema, incontinence, excess moisture, diabetes, vascular disease. 6. IIA

The Braden Scale for predicting pressure injury risk is a validated tool that allows nurses to reliably score adult

patients level of risk for developing pressure injuries. 1. IVA

The Braden QD Scale is a validated tool that allows nurses to reliably score pediatric patients level of risk for

developing pressure injuries.

The incidence of pressure ulcers and their complications can be significantly reduced with optimal nursing

intervention, combined with patient and caregiver participation and education. 6. IIA

Pressure injuries generally develop over bony prominences and are an ischemic response to sustained pressure

and/or damaging forces (shear, friction, moisture). This ischemic response can result in soft tissue death. 6. IIA

PROCEDURE or PROTOCOL

► Requires an LIP order__

Responsible Person

Steps

RN

PATIENT ASSESSMENT

Bony prominence sites

Initial skin assessment

A skin assessment is performed and documented within 12 hours of admission on all patients,

as well as prior to any elective procedure. Assessment head to toe and front to back skin

assessment includes:



1. Examination under skin folds, under all potential pressure points, and under any

devices, unless contraindicated due to physiologic instability.

2. The RN completes the admission screening, the Braden Scale (adults) and Braden QD

(pediatrics), and the skin/wound assessment in the electronic medical record (EMR).

NOTE: For pediatric and neonatal patients, review the visual aids in the Skin Injury

Prevention Related to Respiratory Therapy policy.

NOTE: A pressure injury documented within 24 hours of admission is considered to be

present on admission (POA). 2. National Guidelines

RN, LIP

3. If the patient is found to be at risk for developing a pressure injury, the Pressure Injury

Prevention Bundle is initiated. Criteria for initiation of the bundle include:

• Braden scale of 18 or less (adults)

• Two of the sub-scores of the Braden have scores of 2 or less (adults)

• Braden QD Scale of 13 or greater (pediatrics)

The Pressure Injury Bundle includes five elements: 1) Skin prophylaxis, 2) Pressure

redistribution, 3) Positioning, 4) Moisture management, and 5) Nutrition support.

4. If the patient is admitted with a dressing, it should be removed by the RN to assess the

skin unless contraindicated. Examples of possible exceptions include:

• Stabilizing braces

• Negative pressure therapy dressings (VAC)

NOTE: RN should clarify exceptions with the LIP. If a VAC dressing has been

in place longer than outlined in the Vacuum Assisted Wound Closure (VAC)

Therapy Management policy for frequency of dressing changes, the LIP should

be notified.

► Review orders for surgical wounds or patients post procedure, as these may have

been placed by the LIP post procedure.

RN, LIP, WON

5. Each alteration in skin integrity (pressure-related and non-pressure-related) must have a

new LDA added in the EMR. At a minimum, the RN is expected to document the

location, measurements and color of the wound bed, and actions or interventions taken.

Each dressing change is dated and timed on the dressing and documented in the

flowsheet.

Pressure Injury assessment

If the patient has a pressure injury present on admission (POA) or develops a hospital

acquired pressure injury (HAPI):

See addendum, Present on Admission: Pressure Ulcer Documentation Process.

1. Notify LIP of pressure injury (POA or HAPI). The LIP is responsible for documenting

the POA pressure injury in the admission history and physical (H&P). 2. National Guidelines

2. At a minimum, the RN is expected to document the location, measurements and color

of the wound bed, and actions or interventions taken upon discovery of the pressure

injury. 6. IIA








3. The bedside nurse may identify and document Stage 1 pressure injuries. Remove the

pressure source from the area (i.e., turn patient or reposition). Wait 30 minutes and

then reassess the wound by testing for blanchability. 6. IIA

4. Aside from Stage 1 pressure injuries, the pressure injury is staged by a WON and those

RNs who have completed pressure injury staging education modules with documented

competency.

5. A wound care consult is needed for any injury other than a Stage 1.

6. Photograph the injury and placing the picture into the EMR. See Using Digital

Photography for Patient Care (Haiku Photo Capture).

7. If the pressure injury is hospital acquired: the nurse is to initiate the Pressure Injury

Debrief and Handoff. This form is to be completed, a copy is to be provided to the unit

manager, and the original is to accompany the patient should the patient transfer to

another unit. The checklist should be completed, which includes initiating an eQVR

and obtaining a wound care consult.

RN

Ongoing skin assessment

Ongoing assessment is completed by the RN a minimum of every shift and documented in the

assessment flow sheet of the EMR. The documentation includes any alteration in skin integrity,

new risk factors, and actions taken. The pressure injury prevention bundle is initiated if the

patient is found to be at risk:

• Braden scale of 18 or less (adults)

• Two of the sub-scores of the Braden have scores of 2 or less (adults)

• Braden QD Scale of 13 or greater (pediatrics)

RN, LIP

BASIC SKIN CARE / PRESSURE INJURY BUNDLE

Patients at SMC will receive basic skin care. Elements of this include:

Skin Prophylaxis

1. Consider the use of certain devices for prevention of pressure injury. These devices

include a silicone bordered sacral dressing (see Sacral Dressing Application for

Pressure Ulcer Prevention). 4. IVB

2. Off-loading cushions for chairs. 4. IVB

3. Use of pillows and protective heel boots to float heels or other areas. Use of these

devices is particularly important in patients who are at high risk for pressure injury.4. IVB

NOTE: The use of such devices does NOT replace regular skin inspection and

frequent repositioning. 4. IVB

Pressure redistribution

1. Most adult and bedded pediatric patients at SMC are on a low air loss/pressure-

redistribution surface. Some patients will need alternative surfaces based on special

needs (i.e. bariatric surface). 4. IVB

2. Use single-layer breathable pads. There should be no more than 3 layers of pads and/or

linens between the patient’s skin and the air mattress. 3. Protect the patient from lying on lines, tubes and wrinkled linen.4. IVB

4. Position to avoid allowing the body tissue to be compressed or under pressure from bed

rails, arms of chairs, etc. 4. IVB

5. Regardless of Braden Score or Braden QD score, all efforts should be made to reduce

pressure over bony prominences and under medical devices.4. IVB

NOTE: The turn assist feature on beds does not offload the sacral pressure. This

feature should primarily be used during the physical act of turning the patient to

help the staff member with the turn. 4. IVB









NOTE: Head of Bed greater than 45 degrees should be avoided for extended

periods of time to minimize sacral pressure. As warranted by patient condition

and LIP orders, alternatives to this are HOB at 30 degrees and Reverse

Trendelenburg. 4. IVB

Head of bed, bassinet, crib for pediatrics is patient dependent. If they are on the

ventilator-associated prevention protocol, review Ventilator-Associated

Pneumonia (VAP) Bundle: Pediatric.

NOTE: Specialty beds, including air fluidized beds do not eliminate or minimize

the frequency of the turning and repositioning requirement.

RN, LIP

Positioning (EMR: Keep Turning/Repositioning)

1. All patients, regardless of presumed ability, may need assistance with

positioning.6. IIA

2. A turn schedule is initiated if the patient has a total Braden score of 18 or less, or a sub-

score of 2 or less in the mobility, sensory, and/or activity categories for adult patients

and a Braden QD of 13 or greater for pediatric patients. Turn every 2 hours, however

patients may be turned more frequently based upon individual need. 6. IIA

RN, LIP

NOTE: All actual positions must be documented if the patient is on a turn

schedule.

For adult patients, if the Braden score is 18 or less and the patient is able to turn themselves,

their actual position will need to be documented every 2 hours. If the patient does not turn

themselves every 2 hours, the RN should prompt the patient to turn. 6. IIA

NOTE: If an adult patient refuses a turn and has a Braden score of 18 or less, the

refusal should be documented. Notify the LIP for ongoing refusal to turn.

4. When a patient is in the chair, shift the patient’s weight every two hours.4. IVB

Moisture management 1. Bathing: Use disposable washcloths, cleansing foam and pre-moistened wipes for

bathing. The use of pH (hydrogen ion concentration) neutral soap is encouraged. Use

of wash basins is discouraged due to infection control.

2. Incontinence hygiene:

a. Patients who are incontinent should receive prompt care to avoid skin

breakdown. This includes, but is not limited to toileting schedules and

moisture barrier products.

b. Do not use adult briefs unless the adult patient is out of bed.

c. While in bed, one incontinence pad is preferred under the patient.

d. Do not leave a patient on a bedpan for greater than 10-15 minutes.

e. Use moisture protection devices, creams, ointments to keep skin folds dry,

change as needed.

Nutrition

1. For adults with a Braden Nutrition subscore of 2 or less, a nutrition consult should be

placed in the EMR.3. IIIA Pediatric patients receive a nutrition review, but if the nurse is

concerned, they may place a nutrition consult.

2. Consider lab values that may indicate nutritional risk (i.e. Albumin, Prealbumin,

Hemoglobin A1C, and Transferrin). Patients with disease processes which may cause

nutritional compromise should be considered at risk also (i.e. Renal Disease, Cancer,

Crohn’s disease, etc.).3. IIIA





2. A patient who is NPO is not automatically at risk. However, consider recent nutritional

deficit (lengthy NPO status, poor caloric intake, and/or poor glucose control).3. IIIA

3. The RN is responsible for verifying the nutrition consult and maintaining or initiating

the nutritional interventions established by the dietary department.

RN, WON

SKIN AND WOUND TREATMENT 1. Nursing interventions: When a wound is present and the WON is not available to

consult, the RN should utilize the Wound Care: Complex policy.

NOTE: Ultimately, the dressing selection is less important in the healing of a

pressure injury than aggressive pressure relief to the injured area.

2. Cleanse or irrigate all wounds with normal saline prior to the application of dressings.

3. The pressure ulcer bundle is instrumental in both prevention and treatment of all

pressure injuries.

RN, LIP

Moisture-Associated Skin Damage (MASD) (This includes incontinence-associated dermatitis [IAD]) 7. IVA

1. Assess the cause of MASD and discuss interventions with the LIP.

2. Assess for signs/symptoms of yeast infection, report to LIP if applicable.

3. Skin care once a shift and PRN due to stooling:

a. Clean with foam or spray cleanser and pat dry.

► b. If yeast is present (appears bright red and may have red pustules), apply

antifungal powder or cream per order, obtained through the Pharmacy).

c. Apply moisture barrier products liberally to all affected areas.

d. Notify the wound care nurse if there is no improvement after 48 hours.

► e. Consider a fecal management system if applicable.




Skin Tears 1. Cleanse the area with normal saline.

2. If the loose skin flap is still hanging, then bring it together with a cotton tip applicator

to cover the exposed area.

3. Apply a non-adhesive contact dressing.

4. Cover with dry gauze and Kerlix (roll gauze), secure with a tubular dressing. If the

skin tear is in an area where tubular dressings are not feasible, use dry gauze and secure

with tape. Minimize the amount of tape directly on the skin.

5. Use No Sting Barrier film around the peri-wound areas to reduce risk of maceration,

and also where tape is required to secure the dressing.

6. Consult wound care nurse for large or extensive skin tears.

7. Consult the LIP if localized signs of infection or inflammation are noted.

Definitions

Blanchable – skin erythema that loses all redness when pressed and is due to vascular dilation.

Non-blanchable erythema indicates the presence of red blood cells outside of the blood vessels

(extravasation).

Forms

♦ Pressure Injury Debrief & Handoff Form

Supplemental Information

None.

Regulatory Requirement

1. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2015). Condition of participation: Patient's rights. 42 C.F.R. § 482.13(c)(1).

2. DNV GL-Healthcare USA, Inc. (2014). IC.1.SR.1. NIAHO® accreditation requirements: Interpretive

guidelines & surveyor guidance (version 11). Milford, OH: DNV GL-Healthcare USA, Inc.

References

1. Bergstrom, N., & Braden, B. (n.d.). Braden Scale for Predicting Pressure Sore Risk. Retrieved January

3, 2017, from http://www.bradenscale.com/images/bradenscale.pdf

2. Centers for Medicare & Medicaid Services. (2016). OASIS-C2 guidance manual-effective 1-1-2017. Chapter 3: F-1. Retrieved January 3, 2017, from https://www.cms.gov/Medicare/Quality- InitiativesPatient-

Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-C2- Guidance-Manual- 6-29-16.pdf

3. Doley, J. (2010). Nutrition management of pressure ulcers. Nutrition in Clinical Practice, 25, 50–60.

4. McInnes, E., et al. (2011). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, 2011(4), CD001735.

5. Sernekos, L. A. (2013). Nutritional treatment of pressure ulcers: What is the evidence? Journal of the American Association of Nurse Practitioners, 25, 281–288. Accessed January 17, 2017 via the Web at

http://onlinelibrary.wiley.com/doi/10.1002/2327-6924.12025/pdf

6. Wound, Ostomy and Continence Nurses Society. (2016). Wound, Ostomy and Continence Nurses Society’s guidance on OASIS-C2 integumentary items: Best practice for clinicians. Mt. Laurel, NJ: Pierce, B.


http://www.bradenscale.com/images/bradenscale.pdf

https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-C2-Guidance-Manual- 6-29-16.pdf

https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-C2-Guidance-Manual- 6-29-16.pdf

http://onlinelibrary.wiley.com/doi/10.1002/2327-6924.12025/pdf



7. Zulkowski, K. (2012). Diagnosing and treating moisture-associated skin damage. Advances in Skin & Wound

Care, 25, 231–236 8. Curley, MAQ, Hasbani, NR, Quigley, SM, Stellar, JJ, Pasek, TA, Shelley, SS, Kulik, LA, Chamblee, TB,

Dilloway, MA, Caillouette, CN, McCabe, MA, Wypij, D. Predicting pressure injury risk in pediatric patients:

the Braden QD Scale. J Pediatr 2018;192:189-95.

9. Chamblee, TB, Pasek, TA, Caillouette, CN, Stellar, JJ, Quigley, SM, Curley, MAQ. How to Predict Pediatric Pressure Injury Risk with the Braden QD Scale. Am J Nurs. 2018 Nov;118(11):34-43.

Addenda

Addendum 1- Pressure Ulcer Staging, Example 1

Addendum 2- Braden Scale

Addendum 3- Pressure Ulcer Staging, Example 2

How to Order a Specialty Bed / Bariatric Bed and Rental Products

Specifications for Specialty Beds

Nail Care

Pediatric Braden QD Scale

Pressure Injury Debrief and Handoff

Specialty Bed Order Algorithm (Edmonds only)

Skin Care for End of Life Care

STAKEHOLDERS

Author/Contact

Birgit Petersen, BSN, RN, CWCN, Skin NQL Leader

Nicole Roehrig, MSN, RN, CPN. Pediatric Clinical Nurse Specialist

Expert Consultants

HAPI Steering Team (March 2017)

Wound Healing Center

Pediatric Quality and Safety Committee (Dec 2019)

Sponsor Margo Bykonen, MSN, Chief Nursing Officer

01230201.doc(rev.03/12/20)




braden_qd_tool.pdf





© 2020 Swedish Health Services Addendum

Addendum 1 Pressure Ulcer Staging, Example 1

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented

skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual

changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure

injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also

present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible.

Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate

and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture

associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis

(ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).



Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled

wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by

anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may

occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the

extent of tissue loss this is an Unstageable Pressure Injury.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or

bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling

often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an

Unstageable Pressure Injury.



Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed

because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury

will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic

limb should not be softened or removed.

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or

epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often

precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results

from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve

rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue,

subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a

full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic,

neuropathic, or dermatologic condition

Clinical Protocol: SKIN CARE: SKIN CARE: PRESSURE INJURY PREVENTION

© 2020 Swedish Health Services Addendum.

Addendum 2 Braden Scale

Clinical Protocol: SKIN CARE: SKIN CARE: PRESSURE INJURY PREVENTION

© 2020 Swedish Health Services Addendum.

Addendum 3

Pressure Injury Staging, Example 2

April 2017

Stage 1 Stage 2 Stage 3 Stage 4 Deep Tissue

Injury

Unstageable (any wound where the base

is not visible)

Goal:

Protection

Goal:

Protection, moist healing and absorption

Goal:

Protection, fill depth and absorption

Goal:

Protection, fill depth and absorption

Goal:

Protect from pressure, friction,

shear and moisture

Goal:

Protection, fill Depth and debridement likely

Dressing Options:

Apply Skin Sealant to the wound every 24 hours OR

• Apply a barrier cream three times daily and PRN

Dressing Options:

Apply Skin Sealant around the wound every 24 hours

• If the wound has drainage, cover with a foam dressing and change every 3 days and PRN

Dressing Options:

Apply Skin Sealant around the wound every 24 hour See Stage 2

• If the wound is deeper, fill with Hydrofiber then cover with foam dressing every three days and PRN

Dressing Options:


• If the wound is superficial, fill with Hydrofiber and cover with foam every 3 days and PRN

• If the wound is deeper, fill with saline moistened gauze and cover with ABD pad change daily and prn for drainage

Dressing Options:


• Cover the wound with silicone border dressing every 3 days or leave open to air for observation

Dressing Options:


• See Stage 3

• Exception: for dry eschar, Cover only with dry dressing and change daily.