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## Complete Summary

#### GUIDELINE TITLE

Preventing pressure ulcers and skin tears. In: Evidence-based geriatric
nursing protocols for best practice.

#### BIBLIOGRAPHIC SOURCE(S)

Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In:
Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based
geriatric nursing protocols for best practice. 3rd ed. New York (NY):
Springer Publishing Company; 2008 Jan. p. 403-29. \[91 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ayello EA. Preventing
pressure ulcers and skin tears. In: Mezey M, Fulmer T, Abraham I,
Zwicker DA, editor(s). Geriatric nursing protocols for best practice.
2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p.
165-84.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Pressure ulcers

-   Skin tears

#### GUIDELINE CATEGORY

Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Geriatrics\
Nursing\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a standard of practice protocol for:

-   Prevention of pressure ulcers and early recognition of pressure
    ulcer development and skin changes

-   Prevention of skin tears in elderly clients

-   Identification of clients at risk for skin tears

-   Fostering healing of skin tears

#### TARGET POPULATION

-   Older adults with identified intrinsic and/or extrinsic risk factors
    for pressure ulcers, including:

    -   Immobility as seen in bedbound or chair-bound patients and those
        unable to change positions

    -   Undernutrition or malnutrition

    -   Incontinence

    -   Friable skin

    -   Impaired cognitive ability

    -   Braden scale risk score

-   Older adults at risk for skin tears

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment of Pressure Ulcers**

1.  Risk assessment

    -   Braden Risk Score

2.  Stage I pressure ulcers in patients with darkly pigmented skin

3.  Prevention strategies

    -   Braden Risk Score

**Management of Pressure Ulcers**

1.  Risk assessment documentation

2.  Care issues and interventions: mobilization, skin care, moisture,
    positioning, use of devices, nutrition, friction and shear

**Assessment of Skin Tears**

1.  Risk assessment

    -   Three group risk assessment tool

    -   Payne-Martin classification system

2.  Prevention

    -   Safe environment

    -   Staff/caregiver education

    -   Protect from self-injury and skin injury during routine care

**Management/Treatment of Skin Tears**

1.  Assess size of wound

2.  Cleaning wounds

3.  Application and removal of dressings

4.  Use of skin sealants, protective ointments, liquid barriers

#### MAJOR OUTCOMES CONSIDERED

-   Prevalence of new pressure ulcers

-   Prevalence of nonhealing pressure ulcers

-   Prevalence of skin tears

-   Prevalence of nonhealing skin tears

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Although the AGREE instrument (which is described in Chapter 1 of the
original guideline document) was created to critically appraise clinical
practice guidelines, the process and criteria can also be applied to the
development and evaluation of clinical practice protocols. Thus the
AGREE instrument has been expanded for that purpose to standardize the
creation and revision of the geriatric nursing practice guidelines.

**The Search for Evidence Process**

Locating the best evidence in the published research is dependent on
framing a focused, searchable clinical question. The PICO format---an
acronym for population, intervention (or occurrence or risk factor),
comparison (or control), and outcome---can frame an effective literature
search. The editors enlisted the assistance of the New York University
Health Sciences librarian to ensure a standardized and efficient
approach to collecting evidence on clinical topics. A literature search
was conducted to find the best available evidence for each clinical
question addressed. The results were rated for level of evidence and
sent to the respective chapter author(s) to provide possible
substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation to its level of evidence,
each citation was given a general classification, coded as \"Risks,\"
\"Assessment,\" \"Prevention,\" \"Management,\"
\"Evaluation/Follow-up,\" or \"Comprehensive.\" The citations were
organized in a searchable database for later retrieval and output to
chapter authors. All authors had to review the evidence and decide on
its quality and relevance for inclusion in their chapter or protocol.
They had the option, of course, to reject or not use the evidence
provided as a result of the search or to dispute the applied level of
evidence.

**Developing a Search Strategy**

Development of a search strategy to capture best evidence begins with
database selection and translation of search terms into the controlled
vocabulary of the database, if possible. In descending order of
importance, the three major databases for finding the best primary
evidence for most clinical nursing questions are the Cochrane Database
of Systematic Reviews, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO
database was used to ensure capture of relevant evidence in the
psychology and behavioral sciences literature for many of the topics.
Synthesis sources such as UpToDate^®^ and British Medical Journal (BMJ)
Clinical Evidence and abstract journals such as *Evidence Based Nursing*
supplemented the initial searches. Searching of other specialty
databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit
the search to articles tagged with the publication type
\"meta-analysis\" in Medline or \"systematic review\" in CINAHL.
Filtering by standard age groups such as \"65 and over\" is another
standard categorical limit for narrowing for relevance. A literature
search retrieves the initial citations that begin to provide evidence.
Appraisal of the initial literature retrieved may lead the searcher to
other cited articles, triggering new ideas for expanding or narrowing
the literature search with related descriptors or terms in the article
abstract.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The guideline developers reviewed a published cost-analysis.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC)**: In this update
of the guideline, the process previously used to develop the geriatric
nursing protocols has been enhanced.

Levels of evidence (I--VI) are defined at the end of the \"Major
Recommendations\" field.

**Pressure Ulcers**

**Parameters of Assessment**

-   Assess for intrinsic and extrinsic risk factors

-   Braden Scale risk score

    -   18 or below for elderly and persons with darkly pigmented skin

    -   16 or below for other adults

**Nursing Care Strategies and Interventions**

-   Risk assessment documentation

    -   On admission to a facility

    -   Reassessment intervals whenever the client´s condition changes
        and based on patient care setting:

        -   Acute care: every 48 hours

        -   Long-term care: weekly for first 4 weeks, then monthly to
            quarterly

        -   Home care: every nursing visit

    -   Use a reliable and standardized tool for doing a risk assessment
        such as the Braden Scale (see \"Try This: Predicting Pressure
        Ulcers\" in Resources at
        [www.ConsultGeriRN.org](http://www.consultgerirn.org/))

    -   Document risk assessment scores and implement prevention
        protocols based on cut score

-   General care issues and interventions

    -   Culturally sensitive early assessment for stage I pressure
        ulcers in clients with darkly pigmented skin

        -   Use a halogen light to look for skin color changes\--may be
            purple hues

        -   Compare skin over bony prominences to surrounding skin\--may
            be boggy or stiff, warm or cooler

    -   Agency for Health Care Policy and Research (now known as the
        Agency for Healthcare Research and Quality, AHRQ) (AHCPR, 1992)
        prevention recommendations:

        -   Assess skin daily.

        -   Clean skin at time of soiling; avoid hot water and
            irritating cleaning agents.

        -   Use moisturizers on dry skin.

        -   Do not massage bony prominences.

        -   Protect skin of incontinent clients from exposure to
            moisture.

        -   Use lubricants, protective dressings, and proper lifting
            techniques to avoid skin injury from friction/shear during
            transferring and turning of clients.

        -   Turn and position bedbound clients every 2 hours if
            consistent with overall care goals.

        -   Use a written schedule for turning and repositioning
            clients.

        -   Use pillows or other devices to keep bony prominences from
            direct contact with each other.

        -   Raise heels of bedbound clients off the bed; do not use
            donut-type devices (Gilcreast, et al. 2005 **\[Level
            II\]**).

        -   Use a 30-degree lateral side lying position; do not place
            client directly on their trochanter.

        -   Keep head of the bed at lowest height possible.

        -   Use lifting devices (trapeze, bed linen) to move clients
            rather than dragging them in bed during transfers and
            position changes.

        -   Use pressure-reducing devices (static air, alternating air,
            gel, water mattresses) (Iglesias et al., 2006 **\[Level
            II\]**; Hampton & Collins, 2005 **\[Level II\]**).

        -   Reposition chair or wheelchair bound clients every hour. In
            addition, if client is capable, have them do small weight
            shifts every 15 minutes.

        -   Use a pressure-reducing device (not a donut) for chair-bound
            clients.

    -   Other care issues and interventions

        -   Keep the patient as active as possible; encourage
            mobilization.

        -   Do not massage reddened bony prominences.

        -   Avoid positioning the patient directly on their trochanter.

        -   Avoid use of donut-shaped devices.

        -   Avoid drying out the patient\'s skin; use lotion after
            bathing.

        -   Avoid hot water and soaps that are drying when bathing
            elderly. Use body wash and skin protectant (Hunter et al.,
            2003 **\[Level III\]**).

        -   Teach patient, caregivers, and staff the prevention
            protocols.

        -   Manage moisture:

            -   Manage moisture by determining the cause; use absorbent
                pad that wicks moisture.

            -   Offer a bedpan or urinal in conjunction with turning
                schedules.

        -   Manage nutrition:

            -   Consult a dietician and correct nutritional deficiencies

            -   Increase protein and calorie intake and A, C, or E
                vitamin supplements as needed (Houwing et al., 2003
                **\[Level II\]**; Centers for Medicare and Medicaid
                Services \[CMS\], 2004 **\[Level V\]**).

            -   Offer a glass of water with turning schedules to keep
                patient hydrated.

        -   Manage friction and shear:

            -   Elevate the head of the bed no more than 30 degrees.

            -   Have the patient use a trapeze to lift self up in bed.

            -   Staff should use a lift sheet or mechanical lifting
                device to move patient.

            -   Protect high-risk areas such as elbows, heels, sacrum,
                back of head from friction injury.

-   Interventions linked to Braden risk scores (Adapted from Ayello &
    Braden, 2001)

> Prevention protocols linked to Braden risk scores are as follows:

-   At-risk: score of 15 to 18

    -   Frequent turning; consider every 2 hour schedule; use a written
        schedule.

    -   Maximize patient\'s mobility.

    -   Protect patient\'s heels.

    -   Use a pressure-reducing support surface if patient is bed- or
        chair-bound.

-   Moderate risk: score of 13 to 14

    -   Same as above but provide foam wedges for 30-degree lateral
        position.

-   High risk: score of 10 to 12

    -   Same as above, but add the following:

        -   Increase the turning frequency.

        -   Do small shifts of position.

-   Very high risk: score of 9 or below

    -   Same as above, but use a pressure relieving surface.

    -   Manage moisture, nutrition, and friction/shear.

**Follow-up Monitoring of Condition**

-   Monitor effectiveness of prevention interventions.

-   Monitor healing of any existing pressure ulcers.

**Skin Tears**

**Parameters of Assessment**

-   Use the three-group risk assessment tool (White, Karam & Cowell,
    1994 **\[Level IV\]**) to assess for skin tear risk.

-   Use the Payne and Martin (1993 **\[Level IV\]**) classification
    system to assess clients for skin tear risk:

    -   Category I: a skin tear without tissue loss

    -   Category II: a skin tear with partial tissue loss

    -   Category III: a skin tear with complete tissue loss, where the
        epidermal flap is absent

**Nursing Care Strategies and Interventions** (Baranoski, 2000 **\[Level
V\]**)

-   Preventing skin tears

    -   Provide a safe environment:

        -   Do a risk assessment of elderly patients on admission.

        -   Implement prevention protocol for patients identified as at
            risk for skin tears.

        -   Have patients wear long sleeves or pants to protect their
            extremities (Bank, 2005 **\[Level IV\]**).

        -   Have adequate light to reduce the risk of bumping into
            furniture or equipment.

        -   Provide a safe area for wandering.

    -   Educate staff or family caregivers in the correct way of
        handling patients to prevent skin tears. Maintain nutrition and
        hydration:

        -   Offer fluids between meals.

        -   Use lotion, especially on dry skin on arms and legs, twice
            daily (Hanson et al., 2005 **\[Level III\]**).

        -   Obtain a dietary consult.

    -   Protect from self-injury or injury during routine care:

        -   Use a lift sheet to move and turn patients.

        -   Use transfer techniques that prevent friction or shear.

        -   Pad bedrails, wheelchair arms, and leg supports (Bank, 2005
            **\[Level IV\]**).

        -   Support dangling arms and legs with pillows or blankets.

        -   Use non-adherent dressings on frail skin.

            -   Apply petroleum-based ointment, steri-strips, or a moist
                nonadherent wound dressing such as hydrogel dressing
                with gauze as a secondary dressing. Telfa type dressings
                are also used.

            -   If you must use tape, be sure it is made of paper, and
                remove it gently. Also, you can apply the tape to
                hydrocolloid strips placed strategically around the
                wound rather than taping directly onto fragile
                surrounding skin around the skin tear.

        -   Use gauze wraps, stockinettes, flexible netting, or other
            wraps to secure dressings rather than tape.

        -   Use no-rinse soapless bathing products (Birch & Coggins,
            2003 **\[Level IV\]**; Mason, 1997 **\[Level IV\]**).

        -   Keep skin from becoming dry, apply moisturizer (Hanson et
            al., 2005 **\[Level III\]**; Bank, 2005 **\[Level IV\]**).

-   Treating skin tears (Baranoski & Ayello, 2004 **\[Level V\]**)

    -   Gently clean the skin tear with normal saline.

    -   Let the area air dry or pat dry carefully.

    -   Approximate the skin tear flap.

    -   Use caution if using film dressings as skin damage can occur
        when removing dressings.

    -   Consider putting an arrow to indicate the direction of the skin
        tear on the dressing to minimize any further skin injury during
        dressing removal.

        -   Skin sealants, petroleum-based products, and other
            water-resistant product such as protective barrier ointments
            or liquid barriers may be used to protect the surrounding
            skin from wound drainage or dressing/tape removal trauma.

        -   Always assess the size of the skin tear, consider doing a
            wound tracing.

        -   Document assessment and treatment findings.

**Follow-up Monitoring of Condition**

Continue to reassess for any new skin tears in older adults.

**Definitions**:

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12262)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Pressure Ulcers**

**Patient**

-   Skin will remain intact.

-   Pressure ulcer(s) will heal.

**Provider/Nurse**

-   Accurate performance of pressure ulcer risk assessment using
    standardized tool

-   Implementation of pressure ulcer prevention protocols for clients
    interpreted as at risk for pressure ulcers

-   Performance of a skin assessment for early detection of pressure
    ulcers

**Institution**

-   Reduction in development of new pressure ulcers

-   Increased number of risk assessments performed

-   Cost-effective prevention protocols developed

**Skin Tears**

-   Absence of skin tears in at-risk clients

-   Skin tears that do occur will heal

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Resources\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In:
Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based
geriatric nursing protocols for best practice. 3rd ed. New York (NY):
Springer Publishing Company; 2008 Jan. p. 403-29. \[91 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008 Jan)

#### GUIDELINE DEVELOPER(S)

Hartford Institute for Geriatric Nursing - Academic Institution

#### GUIDELINE DEVELOPER COMMENT

The guidelines were developed by a group of nursing experts from across
the country as part of the Nurses Improving Care for Health System
Elders (NICHE) project, under sponsorship of The John A. Hartford
Foundation Institute for Geriatric Nursing.

#### SOURCE(S) OF FUNDING

Supported by a grant from the John A. Hartford Foundation.

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Elizabeth A. Ayello and R. Gary Sibbald

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ayello EA. Preventing
pressure ulcers and skin tears. In: Mezey M, Fulmer T, Abraham I,
Zwicker DA, editor(s). Geriatric nursing protocols for best practice.
2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p.
165-84.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Hartford Institute for Geriatric
Nursing Web
site](http://consultgerirn.org/topics/pressure_ulcers_and_skin_tears/want_to_know_more).

Copies of the book *Geriatric Nursing Protocols for Best Practice*, 3rd
edition: Available from Springer Publishing Company, 536 Broadway, New
York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web:
[www.springerpub.com](http://www.springerpub.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The followings are available:

-   Predicting pressure ulcer risk. Try this: best practices in nursing
    care to older adults. 2007. Electronic copies available from the
    [Hartford Institute for Geriatric Nursing Web
    site.](http://www.hartfordign.org/publications/trythis/issue05.pdf)

-   Nursing care strategies/treatment/management and pressure ulcer
    staging system are available from the [Hartford Institute for
    Geriatric Nursing Web
    site](http://consultgerirn.org/topics/pressure_ulcers_and_skin_tears/want_to_know_more).

-   Pressure ulcers/skin tears: post-test instructions are available
    from the Continuing education activity. Available from the [Hartford
    Institute for Geriatric Nursing Web
    site](http://consultgerirn.org/continuing_ed#instr).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 30, 2003. The information was
verified by the guideline developer on August 25, 2003. This summary was
updated on June 19, 2008. The updated information was verified by the
guideline developer on August 4, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
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Readers with questions regarding guideline content are directed to
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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008