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

parameter 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. Staff education, Skin Resource Nurse, reduction
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of risk factors, interventions to reduce the development of altered skin integrity, and pressure

reduction equipment will be discussed.

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

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

effects 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
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 4

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

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

blood to the body and extremities. Identifying and reducing the risk factors of patients is a part of

reducing the incidence of skin breakdown. Educating employees about this information is also

crucial to decrease the occurrence of pressure injuries. (Knoch Mendonça, Dias Rolan Loureiro,

Antonio Ferreira Júnior, & Schiaveto de Souza, 2018)

Staff education

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

the 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
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to keep staff consistent with care. In order to validate the staff’s education was up to par, a

wound liaison nurse and wound team compiled 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 developed, it ensures consistency within

treatment. Ackerman (2011) states, “The positive trend in reduction of nosocomial skin

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 I pressure ulcers to only six stage II, and four

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

surgical unit was successful in reducing the amount of nosocomial pressure ulcers, and the
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 6

declining amount 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

hospital’s 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. (Ackerman, 2011)

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 (Jackson et al., 2011). For this reason, pressure

reduction equipment is 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 (Jackson et al., 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
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(Jackson et al., 2011. This shows a positively large difference between those using the Air

Fluidized Beds and those not using the Air Fluidized Beds.

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 (Jackson et al., 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

pressure ulcers (Bergstrom et al., 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 et al., 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. Although these implantations are

helpful, seldom are these interventions continued throughout all patient care settings.

Continuity of Care

When providing care for patients at a high risk for pressure ulcer formation it’s necessary

to preform preventative care consistently and efficiently. According to (x) the "the frequency of
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 8

PRSS use was only 57% in the initial acute care setting" in patients that showed multiple signs of

being a high risk candidate for skin breakdown. Although interventions were being implemented

in high risk patients more than half of the time in the acute care setting, which is not the trend for

the patients’ secondary care. Facilities such as inpatient rehabilitation centers only use the

interventions previously performed less than half of the time. Along with nursing home

interventions weighing in "less than one quarter of those in the initial acute care setting" (x). In

order to reduce the occurrence of altered skin integrity, nurses must apply interventions to their

clinical practice to reduce the development of pressure injuries.

Interventions to Reduce 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 patients due to potential

complications that can arise. Intensive care unit (ICU) 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 ICU pose a uniquely high risk of developing an

alteration in skin integrity. (Coyer, et al., 2015)

This study (Coyer, et al., 2015) 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 ICU 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.

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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 ICU.

The intervention group received a skin assessment within the first four hours of admission to the

ICU. 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 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

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

and periwound assessment. The control group received an ongoing skin assessment once per day,

and was only documented as intact or not 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

intervention 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.
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 10

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

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

were 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 1.26

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.

INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 11

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

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 continue to improve patient

outcomes. (Coyer, et al., 2015)

Conclusion
INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN 12

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