Identify at-risk individuals needing prevention and the specific factors placing them
Bed- and Chair-Bound Individuals
Bed- and chair-bound individuals or those with impaired ability to reposition should be
assessed for additional factors that increase risk for developing pressure ulcers.
These factors include immobility, incontinence, nutritional factors such as inadequate dietary
intake and impaired nutritional status, and altered level of consciousness.
Individuals should be assessed on admission to acute care and rehabilitation hospitals,
nursing homes, home care programs, and other health care facilities.
A systematic risk assessment can be accomplished by using a validated risk assessment tool
such as the Braden Scale or Norton Scale. Pressure ulcer risk should be reassessed at periodic intervals. (Strength of Evidence
= A.) All assessments of risk should be documented. (Strength of Evidence = C.)
To prevent pressure ulcers, individuals at risk must be identified so that risk factors
can be reduced through intervention. The primary risk factors for pressure ulcers are immobility and limited activity levels.
Therefore, persons with impaired ability to reposition themselves or those whose activity
is limited to bed or any chair should be assessed for their risk of developing a pressure ulcer. To determine the magnitude
of risk, the degree to which mobility and activity levels are limited can be quantified. Both the Norton Scale and the Braden
Scale assess these factors. Instructions on use of both scales are available.
Other risk factors for pressure ulcer development include incontinence, impaired nutritional
status, and altered level of consciousness.
Incontinence is assessed by the Moisture subscale of the Braden Scale and the Incontinence
component of the Norton Scale Nutritional factors are considered indirectly in the General Condition component of the Norton
Scale and the Nutritional Status subscale of the Braden Scale. Altered level of consciousness is assessed by the Norton Scale's
Mental Condition subscale and the Braden Scale's Sensory Perception subscale.
Numerous risk assessment tools exist; however, only the Braden Scale and the Norton Scale
(original, and modified) have been tested extensively. The Braden Scale has been evaluated in diverse sites that include medical-surgical
units, intensive care units, and nursing homes. The Norton Scale has been tested with elderly subjects in hospital settings.
The reported sensitivity and specificity of these risk assessment tools have varied greatly.
This variability probably reflects differences in study settings, populations, and outcome measures. Some studies have included
Stage I ulcers as an outcome with inconsistent definitions of these lesions. The degree to which preventive interventions
have been implemented in response to the findings of the risk assessments in these studies may have also contributed to the
variability in their reported performance. Good interrater reliability for the Braden Scale has been reported Reliability
data are not available for the Norton Scale, and the original version did not include definitions for its subscales . Modifications
of the Norton Scale have included such definitions.
Despite the limitations of the Norton and Braden scales, their use ensures systematic evaluation
of individual risk factors. No information is currently available to suggest that adaptations of these risk assessment tools
or the assessment of any single risk factor or a combination of risk factors predict risk as well as the overall scores obtained
by the tools.
The condition of an individual admitted to a health care facility is not static; consequently,
pressure ulcer risk requires routine re-examination. The frequency with which such re-evaluations need to be done is unknown.
However, if an individual becomes bed- or chair-bound or develops difficulty with repositioning, pressure ulcer risk needs
to be assessed. Accurate and complete documentation of all risk assessments ensures continuity of care and may be used as
a foundation for the skin care plan.
Skin Care and Early Treatment
Goal:Maintain and improve tissue tolerance to pressure in order to prevent
All individuals at risk should have a systematic skin inspection at least once a day, paying
particular attention to the bony prominences. Results of skin inspection should be documented. (Strength of Evidence = C.)
It is customary practice to include procedures for inspecting skin in an overall skin care
program that also includes interventions. As a result, the exact role that a systematic, comprehensive, and routine skin inspection
plays in decreasing the incidence of pressure ulcers has not been identified. For this guideline, it was deemed sufficient
that health care professionals advocate skin inspection as fundamental to any plan for preventing pressure ulcers. Skin inspection
provides the information essential for designing interventions to reduce risk and for evaluating the outcomes of those interventions.
Skin cleansing should occur at the time of soiling and at routine intervals. The frequency
of skin cleansing should be individualized according to need and/or patient preference. Avoid hot water, and use a mild cleansing
agent that minimizes irritation and dryness of the skin. During the cleansing process, care should be utilized to minimize
the force and friction applied to the skin. (Strength of Evidence = C.)
Daily activities result in metabolic wastes and environmental contaminants accumulating
on the skin. For maximum skin vitality, these potentially irritating substances should be removed frequently. If unexpected
contamination occurs, such as fecal or urinary incontinence, the skin should be cleansed as soon as possible to limit chemical
As a person ages, the frequency of routine skin cleansing may decrease because there is
less sebum and perspiration. This reduced frequency of cleansing lessens the magnitude of trauma experienced by the more sensitive
Skin injury due to excess thermal energy or the accelerated metabolic activity induced by
elevated temperature should be minimized by only using wash water that is comfortable (slightly warm) to the skin.
During the cleansing process, some of the skin's natural barrier is removed. The more the
barrier is removed, the drier the skin becomes and the more susceptible it becomes to external irritants. Under most conditions,
the individual's skin is minimally soiled and can be properly cleansed with a very mild cleansing agent that does not disrupt
the natural barrier.
Minimize environmental factors leading to skin drying, such as low humidity (less than 40
percent) and exposure to cold. Dry skin should be treated with moisturizers. (Strength of Evidence = C.)
Preliminary research evidence suggests that a weak association may exist between dry, flaky,
or scaling skin and an increased incidence of pressure ulcer development .
It also appears that adequate hydration of the stratum corneum helps protect against mechanical
insult. The level of stratum corneum hydration decreases with decreasing ambient air temperature, particularly when the relative
humidity of the ambient air is low. Further, the development of clinically dry skin may result from a decreased level of relative
humidity in the ambient air.
Decreased skin hydration results in reduced pliability, and severely dry skin is associated
with fissuring and cracking of the stratum corneum. Also, a number of studies have shown that both the clinical picture of
dry skin and measures of stratum corneum hydration generally improve with the application of various topical moisturizing
Although efficacy of any specific moisturizing agent has not been established, it would
appear prudent to treat clinical signs and symptoms of dry skin with a topical moisturizer.
Further, although there is no direct evidence to support efficacy in preventing pressure
ulcers, maintenance of ambient environmental conditions (relative humidity, and temperature) appears to be prudent to facilitate
stratum corneum hydration and minimize the incidence of dry skin.