Running Head: INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN

Interventions for Preventing Skin Breakdown in Hospitalized Patients

Chloe Vendemia, Alayna O’Rourke, Rachel Crawford, Indiya Benjamin

04/02/2018

NURS 3749: Nursing Research

Dr. Valerie O’Dell

INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 1

Abstract

The purpose of this research was to look at the development of skin breakdown in hospitalized

patients and how hospitals and nurses are implanting interventions for precautionary reasons in

their shift. The correlation between nurse liaisons, preventative techniques, and equipment was

explored. This research was drawn from eight qualitative studies that extensively researched

ways to prevent skin breakdown in hospitalized patients. It was found that there was significant

evidence supporting that adding a nurse liaison to patients care team, preventative interventions

that nursing staff can implement into their daily shift that decrease the amount of nosocomial

decubitus ulcers, and equipment used by the nursing staff for patients reduced the amount of skin

breakdown was successful to reducing the amount of hospital acquired skin breakdown. The time

frame for each research project is within one year. Overall, the research done showed that nurse

liaisons, implementation of skin breakdown prevention, including pressure reduction equipment

into patients care plan impacted the outcome of patients’ skin integrity by decreasing the risk of

skin breakdown and/or healing skin breakdown.

INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 2

Interventions for Preventing Skin Breakdown in Hospitalized Patients

Pressure ulcers, decubitus ulcers, and bedsore are all names used in conjunction to

describe skin breakdown. A pressure ulcer is defined as a reddened area on one’s skin, typically

on a bony prominence, that damages the tissues due to lack of adequate blood flow. Pressure

ulcers have been a reoccurring problem hospitals have been facing for many years. The

consequences pressure ulcers have on patients is numerous; it also causes pain and discomfort.

For hospitals, pressure ulcers cost an abundant amount of money. As common as decubitus ulcers

may be, they should not be mistaken for their potency of resulting in death if not treated

correctly. It is the job of the nurse to give the patient the best care possible in order to prevent

any skin breakdown. The role of the nurse plays a major role in prevention of skin breakdown.

The nurse uses keen assessment skills to recognize signs and symptoms to determine if the

patient is at risk for skin breakdown or has acquired skin breakdown. The hospital is responsible

for educating its employees on proper prevention, recognition, and treatment for skin breakdown.

Therefore, the following research question was addressed: In hospitalized patients, how do

preventative measures implemented to prevent the occurrence of skin breakdown effect the

development of skin breakdown over a one year period.

Literature Review

Introduction

With the intentions of addressing this issue in the nursing profession, information was

acquired via OhioLINK databases, specifically EBSCOhost and CINHAL Plus. Eight sources

were reviewed for an extensive collection of data about the ways hospitals implement

interventions for prevention of skin breakdown through reduction of risk factors, staff education,

skin resource nurse, identifying risk factors in critically ill patients, continuity of care,
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 3

interventions to reduce the development of altered skin integrity, pressure reduction equipment,

pressure reduction dressings, and the reduction of pressure injuries in critically ill patients.

Staff education

The importance of staff education is to make the employees competent and consistent in

their care they are delivering to patients throughout the unit. According to Armour-Burton,

Fields, Outlaw, Deleon (2013) “A major strategy used during the Healthy Skin Project was to

provide comprehensive evidence-based education and training to staff nurses on the assessment,

prevention, and staging of skin lesions and the possible treatment options” (p.36). This allows for

the nurses working on the unit to have consistent education protocol to handling skin breakdown.

As a reminder, posters of skin care products are visible throughout the unit as a reminder to the

staff about accurate product samples, order information, and clinical indications for each product

to keep staff consistent with care. To validate the staff’s education was up to par a wound liaison

nurse and wound team complied a three-part, self-learning, thirty-page educational manual on

skin care. The manual contains photographs of pressure ulcer, skin lesions and staging with

treatment plans. At the end of the manual, a 30-question test is used to evaluate each staff

member’s ability to recognize skin breakdown, staging, and possible treatments (Armour-Burton

et al 2013).

Skin Care Resource Nurse

One important aspect to nursing is adding a Skin Care Resource Nurse to a patient care

plan with skin breakdown can enhance the outcome for the patient. An expert in the field of skin

breakdown allows the patient to receive the best treatment possible. By having one expert

address every pressure ulcer, either developing or has developed, it ensures consistency within

treatment. Ackerman (2011) states, “The positive trend in reduction of nosocomial skin
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 4

breakdown may be linked in part to the recruitment of the Skin Care Resource Nurse…good

nursing care is key to prevention” (p.93). Once an expert is a member of the care team, he or she

can effectively manage skin care needs for patients who are at risk or are experiencing skin

breakdown. Therefore, a Skin Care Resource Nurse decreases the patients’ risk for developing a

pressure ulcer. The hospital adopted an eight-step process for identifying and treating skin

breakdown, with specific protocols for treatment for stages of pressure ulcers to keep consistency

throughout the hospital (Ackerman 2011). Through the study conducted, Ackerman found In

January 2009, once the Skin Care Resource Nurse position was implemented. Pressure ulcers

were dramatically decreased from eleven stage 1 pressure ulcers to only six stages 2, and four

stage 2 ulcers to only two stage 2 pressure ulcers. Using the eight-step method, the medical

surgical unit was successful in reducing the amount of nosocomial pressure ulcers, and the

declining number of ulcers is positively linked to the addition of the Skin Care Resource Nurse

(p.93).

Implementing skin breakdown prevention and adding Skin Care Resource Nurses to a

hospitals health care team has proven, as seen above, to decrease the occurrence, or progression

of skin breakdown. There are other interventions hospitals can implement into their skin

breakdown prevention such as pressure reduction equipment.

Identifying Risk Factors and Incidences of Pressure Injuries in Critically Ill Patients

Identifying and reducing the risk factors of pressure ulcers, injuries, and skin breakdown

in hospitalized patients is important. These types of injuries symbolize a severe public health

crisis, mostly due to frequency of these occurrences and the impact on patients’ lives. Emergence

of skin breakdown is considered a representation of the quality of health care patients receive.

The occurrence of pressure ulcers is common and development is rapid, which can lead to many
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 5

complications. This public health crisis impacts not only patients and their families, but includes

society as a whole. In order to reduce this impact, health care professionals must identify the risk

factors contributing to the incidence of pressure injuries and skin breakdown.

Proposed risk factors have been analyzed; these risk factors can be classified as either

intrinsic or extrinsic. Extrinsic factors can be defined as the elements in the patients’

environment, external to the patient, which can be changed and manipulated. Some of the

extrinsic factors taken into consideration were the type of mattresses used and the condition of

the sheets on the hospital beds. Intrinsic factors are aspects in essence, fundamentally a part of

the patient, and unchangeable. These characteristics include body mass index, gender, age, and

race or ethnicity.

The data collected and analyzed was numerous, in order to identify the risk factors

contributing to skin breakdown. Data was collected from a total of 104 patients from two

institutions. The collected data included body temperature, hemoglobin, white blood cell counts,

nutrition (nothing by mouth versus a general or regular diet), edema, capillary refill, mechanical

ventilation, ambulation, continence versus incontinence, the use of vasoactive drugs, and overall

wellbeing of the patient. Certain factors became more statistically significant than others.

The identified risk factors that emerged as statistically significant were age,

hyperthermia, and edema. According to this study, patients of both genders are equally as likely

to develop pressure ulcers, but age is a greater risk factor. Patients age 59 or older developed

pressure injuries more frequently than the group of younger patients, less than 59 years old.

Hyperthermia was also a risk factor analyzed in this study and found to be statistically

significant. Maintaining control of the microclimate is important, as it has an impact upon the

development of pressure injury formation. Finally, edema was also identified as a statistically
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 6

significant factor in pressure ulcer formation, as edema compromised the circulation oxygen rich

blood to the extremities. Overall, identifying and reducing the risk factors of patients is a part of

reducing the incidence of skin breakdown. [CITATION Placeholder1 \l 1033 ]

Continuity of Care

When providing care for patients that are considered a high risk for pressure ulcer

formation or skin breakdown, it is necessary to preform preventative care consistently and

efficiently. According to (Baumgarten, Margolis, & Orwig, 2010) "the frequency of PRSS use

was only 57% in the initial acute care setting" in patients that have showed significant risk

factors towards skin breakdown. Although interventions were being implemented in half of the

patients in the acute hospital stays, it’s still not enough implementation even in spite of clinical

guidelines and hospital policies recommending or requiring pressure-redistributing support

surfaces (PRSS) for high-risk patients. Patients are more probable to develop skin breakdown in

the acute care settings based of measured acute and chronic risk factors, but do to such short term

acute setting stays the burden of prevention is falling upon rehabilitation and nursing home

facilities. Facilities such as inpatient rehabilitation centers and nursing homes cause an important

deterrent PRRS in patient care. Even though these patients being admitted or returning to these

facilities have already established these individuals at risk or high risk for skin breakdown,

interventions are used “less than half those interventions in the initial acute setting”

(Baumgarten, Margolis, & Orwig, 2010). Along with nursing home facilities only participate in

the use of PRSS interventions "less than one quarter of those used in the initial acute care

setting" (Baumgarten, Margolis, & Orwig, 2010). Although patients in the initial acute setting

are more likely to receive PRSS use do to being at a higher risk of pressure ulcer formation,

many of these patients are headed to these facilities with those same risk factors and
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 7

interventions are still not being considered or used as if they are important to the patient’s quality

of care. The differences among health care settings persist to remain almost unchanged even with

multiple pressure ulcer risk factors “suggesting that the type and quality of preventative care are

important factors” that aren’t being taken into consideration when factoring in the quality of

patient’s care. Preventative measures are one of the most important factors in improving a

patient’s quality of life and maintaining their skin, first line of defense against sickness and

infection. The large differences in health care organizations overall are causing a gap in patients

at risk for skin breakdown, causing a gap and infrequent use of the PRSS interventions that are

expected to be used for these specific patients. The findings that “pressure ulcer risk factors had

little impact on the use of PRSS may also indicate a problem with the quality of care, as pressure

ulcer prevention guidelines recommend the allocation of devices based on the presence of risk

factors” (Baumgarten, Margolis, & Orwig, 2010). Without consistent and efficient PRRS care

across all health care continuum, patients are going to continue to develop breakdown in their

skin that could have been prevented from the start of their care.

Pressure Reduction Equipment

According the Critical Care Nurse (2011), pressure ulcers are always a huge risk for

patients experiencing periods of hypotension, paralysis, or heavy sedation. In many cases,

medical professionals are not able to reposition patients or complete side to side movements

regularly enough to reduce ulcers. There has yet to be information that proves that these ulcers

can be completely preventable. Although a study completed on experts showed that 68% of

respondents believe that these can be preventable (Drumm, J, Jackson, M, LeMaster, T,

McKenney, T, Merrick, B, VanGilder, C, 2011). For this reason, pressure reduction equipment is
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 8

necessary to be put to use. Great improvements in reducing ulcers have come from Air Fluidized

Beds and High-Density Foam Mattresses.

Air Fluidized Beds provide maximal immersion and envelopment. Maceration of the skin

is minimized by these beds because moisture flows into a bed of beads which is used to reduce

shear and friction (Drumm, J, Jackson, M, LeMaster, T, McKenney, T, Merrick, B, VanGilder, C

(2011). In order to qualify for this treatment patients must require vasopressors for at least 24

hours or have received mechanical ventilation for 24 hours or longer. This form of equipment,

although not common, has proven itself various times with its ability to reduce ulcers. In a study

conducted by The Critical Care Nurse (2011) one patient out of twenty-five experienced ulcers

when using this form of prevention. Before these beds were used as prevention, a study showed

that 40 ulcers were formed on the same number of patients (Drumm, J, Jackson, M, LeMaster, T,

McKenney, T, Merrick, B, VanGilder, C, 2011). Thus showing a positively large difference

between those using the Air Fluidized Beds and those not.

On the other hand, critics of Air fluidized beds argue that these preventions are too

expensive and hard to attain. Although, before jumping to conclusions about price, one must

look at the future costs that could arise if these ulcers were not prevented. For example, bed

rentals for a study of twenty-five patients added up to $18,000, while the cost of treatment for

one pressure ulcer in bad condition is a much larger $40,000 (Drumm, J, Jackson, M, LeMaster,

T, McKenney, T, Merrick, B, VanGilder, C, 2011).

However, there are also less expensive alternative beds used to prevent these ulcers as

well. These are high-density foam mattresses. The major difference, other than price, between

this type of bed is that repositioning the patient is essential here to in order to be successful in

reducing these ulcers. Repositioning frequency is based on the resident’s risk for developing
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 9

pressure ulcers (Bergstrom, N, Barrett, R, Horn, S, Rapp, S, Stern, A, Watkiss, M, 2013). In a

study where patients were introduced to high density foam mattresses, ulcers were not

completely eliminated, however not one patient developed Stage Three or Four ulcers

(Bergstrom, N, Barrett, R, Horn, S, Rapp, S, Stern, A, Watkiss, M 2013). This was very

important in that the Ulcers were very treatable.

Although ulcer prevention has not yet arisen as something that can completely taken care

of, equipment should be intervened in order to reduce the problem. Critics will argue that price

and availability are at issue, however this equipment will do much more for patients and in turn

has proven to eliminate future costs and medical problems.

Preventative Foam Dressing

Preventative silicone foam dressings are seen being used to prevent the beginning stages

of skin breakdown over the coccyx and the underside of the heels. The foam dressing is applied

over the bony prominence of the coccyx and the heel of the foot when risk factors indicate

needed interventions, and are changed as needed but left in place over the span of the patient’s

acute care stay. Studies have reported that “silicone foam dressings decreased the incidence of

HAPU’s. The overall effect size across studies indicated that HAPU incidence of sacral area

decreased after the application” preventing the initial start of the skins breakdown (Tayyib &

Coyer, 2016). The same effectiveness of the sacral dressing was similar to that of the heel

breakdown occurrences. Studies showed that “heel HCAPU’s incidence significantly decreased

after the implementation of the dressing” (Tayyib & Coyer, 2016). Eventually showing not

pressure ulcer formation to be reported on the heels following the implementation of the strategy

of the dressing (Tayyib & Coyer, 2016). By providing the extra protective material and padding
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 10

over bony prominences prone to skin breakdown can aid in preventing the overall occurrences of

hospital acquired pressure ulcers.

Reducing Pressure Injuries in Critically Ill Patients

Pressure injuries cause a substantial amount of harm to patients and often time

compromise recovery, leading to complications. The formation of pressure ulcers leads to other

morbid conditions and also increases the mortality of affected patient’s due to potential

complications that can arise. Intensive care unit patients manifest many risk factors including

immobility, use of mechanical ventilation, inability to ambulate or perform basic activities of

daily living, and decreased sensation due to sedative and analgesic medications. Critically ill

patients often populating the Intensive care units pose a uniquely high risk of developing an

alteration in skin integrity.

This study specifically gathered data about the implementation of the Interventional Skin

Integrity Protocol in a high-Risk Environment (InSPiRE) versus a standard hospital protocol.

The data was collected in a twelve-month period in an Intensive care unit of an Australian

metropolitan hospital. The study was comprised of 207 patients in total; 102 were included in the

control group receiving the standard hospital skin care policy implementations, but 105 were in

the intervention group receiving the InSPiRE protocol.

The control group receiving the standard hospitalized care in relation to skin integrity

received a skin assessment within the first twenty-four hours following admission to the

intensive care unit. The intervention group received a skin assessment within the first four hours

of admission to the intensive care unit. Implementation of devices to reduce pressure in the

control group were based upon a scoring system unique to this intensive care unit, while

implantation of pressure reducing devices in the intervention group were made from clinical
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 11

nursing judgement. The ongoing assessment of the intervention group was more detailed and

occurred twice daily, and descriptions pertaining to skin color, moisture, texture, edema, and

turgor were used in the electronic health care record.

An alteration or loss of skin integrity was documented twice daily along with a plan of

management. Images were uploaded to the patients’ electronic health care record, along with a

wound and peri wound assessment. The control group received an ongoing skin assessment once

per day, and was only documented as intact or no intact. In both group patients were bathed once

daily, the intervention group used a pH balances cleansing agent, and treated dry skin with

topical lotions. The control group received a bed bath with soap and water once in the morning

and again at night.

A turning schedule was established for both groups, the interventional group was turned

at a minimum of every two to three hours from left lateral, supine, to right lateral positions, foam

wedges were used to maintain these positions. The control group was turned every two to four

hours as determined by the nurse’s clinical judgement. Other precautions taken in the control

group were the elimination of patients’ contact with plastic surfaces when possible, repositioning

nasogastric tubes and/or endotracheal tubes every 12 hours, use of heel protectors, and elevation

of the calves. These precautions were not strictly followed in the control group.

The results of this study were measured using established tools, demographic data,

clinical data, skin assessment tools, and categorization of pressure injuries. The established tool

used was the sequential organ failure assessment. This scores six body systems on a zero (normal

function) to four (most abnormal dysfunction), this provides a daily score of zero to twenty four

(the latter being the highest and most severe score). The demographics variables collected were
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 12

sex, age, diagnosis upon admission, comorbid conditions, elective versus emergent admission,

length of admission, and discharge or death.

A consistent skin assessment tool based on physical assessment was used; areas of

common pressure injuries were also assessed. Pressure injuries were categorized into skin

injuries and mucous injuries. The pressure injuries were measured using standard guidelines to

stage pressure injuries in stage I, non-blanchable erythema, to stage IV, full thickness tissue loss

with exposure of tendons or muscles. In patients developing pressure injuries, two digital images

were taken and included in the electronic health care record. The location of the pressure injuries

was also documented on a body pictogram.

Most of the participants in this study were men of similar demographic characteristics.

Some major exceptions to the similarities included body mass index and number of secondary

diagnosis. After implementing the specialized group of protocols, the overall occurrence of

pressure injuries were lower in the intervention group, than in the control group. The control

group had significantly more pressure injuries develop overtime. The intervention group

comprised of 19 patients had 24 pressure injuries; this can be inferred to be an average of 1.2

pressure injuries per patient. The control group comprised of 31 patients had a significant

increase, 64 pressure injuries. This can be inferred to be an average of 2.06 pressure injuries per

patient; nearly double the incidence of the intervention group.

In comparison to the control group, the intervention group had approximately one

pressure injury per patient. These injuries were documented as less severe in the interventional

group, than the control group. The occurrence of pressure injuries to the lower extremities,

specifically patients’ heels were significantly more common in the control group. The most
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 13

common area for pressure injuries was the sacrum and coccyx in both the interventional group

and the control group.

Overall, implementation of the InSPiRE protocol led to better patient outcomes. The intervention

group demonstrated a marked reduction in the occurrence and severity of pressure injuries. The

pressure injuries in the intervention group also developed after a longer period of time. The use

of contemporary and evidence based practices will improve patient outcomes. [CITATION

Placeholder2 \l 1033 ]

Conclusion

In conclusion, pressure injuries are a costly expense to the health care system. These

sentinel events cause complications and poor patient outcomes. Most of these pressure injuries

can be prevented with intervention from specialized nursing staff, reduction of risk factors,

specific interventions, and pressure reduction devices. The consequences of pressure ulcers are

numerous, and cause patients pain and discomfort. The frequency and occurrence of pressure

injuries is a representation of the quality of care received by patients in health care

institutions. In order to improve the quality of care, nurses and other health care personnel must

follow precautions and interventions aimed to reduce the occurrence of these pressure related

injuries. Nursing staff must adhere to interventions and protocols, while providing continuity of

care for these patients to enable the reduction of pressure injuries. Overall, pressure injuries can

be prevented through numerous interventions.

References

Ackerman, C. L. (2011). 'Not On My Watch:' Treating and Preventing Pressure Ulcers.

MEDSURG Nursing, 20(2): 86-93.

INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 14

Armour-Burton, T., Fields, W., Outlaw, L., & Deleon, E. (2013). The Healthy Skin Project:

Changing Nursing Practice to Prevent and Treat Hospital-Acquired Pressure Ulcers.

Critical Care Nurse, 33(3): 32-40. doi:10.4037/ccn2013290

Baumgarten, M., Margolis, D., & Orwig, D. (2010). Use of Pressure-Redistributing Support

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Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., Barrett, R., & Watkiss, M. (2013). Turning for

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