Susceptibility of an individual >18 years of age to localized damage to the skin and/or underlying tissue, as a result of pressure, or pressure in combination with shear, which may compromise health (European Pressure Ulcer Advisory Panel, 2019)

• Anemia
• Cardiovascular diseases
• Central nervous system diseases
• Chronic neurologic conditions
• Critical illness
• Decreased serum albumin level
• Decreased tissue oxygenation
• Decreased tissue perfusion
• Diabetes mellitus
• Edema
• Elevated C-reactive protein
• Hemodynamic instability
• Hip fracture
• Immobilization
• Impaired circulation
• Intellectual disability
• Medical devices
• Peripheral neuropathy
• Pharmaceutical preparations
• Physical trauma
• Prolonged duration of surgical procedure
• Sensation disorders
• Spinal cord injuries

• Age
• Integumentary status, including color, elasticity, hygiene, lesions, moisture, sensation, temperature, texture, turgor, and quantity and distribution of hair
• Musculoskeletal status, including muscle strength and mass, joint mobility, paralysis, and range of motion
• Bowel and bladder continence
• Nutritional status, including appetite, dietary intake, hydration, current weight, and change from normal weight
• Hemoglobin and serum albumin levels and hematocrit
• Injuries
• Chronic diseases
• Circulation, especially to bony areas
• Medications
• Body type and weight
• Use of medical devices (e.g., leg braces, oxygen tubing, cervical collar)
• History of previous skin breakdown
• Risk assessment tool (Braden)

• Patient will not experience a pressure ulcer.
• Patient's bony prominences will have limited contact with bedding and mattress.
• Patient will have adequate nutrition.
• Patient will maintain adequate circulation to skin.
• Patient will explain skin care regimen.
• Patient and family members will demonstrate skin care regimen.

Suggested NOC Outcomes

• Inspect patient's skin every shift; document skin condition and report status changes. Early detection of changes prevents or minimizes skin breakdown.
• At regular intervals, monitor skin over bony prominences for redness and blanching. Regular monitoring of patient's skin helps to identify problems early.
• Use pressure redirecting devices, as needed, such as a foam mattress, alternating pressure mattress, gel headrests, sheepskin, pillows, and padding. Devices redirect pressure and assist in avoiding discomfort and skin breakdown.
• Keep patient's skin clean and dry; lubricate, as needed. Don't use irritating soap, and rinse skin well. These measures alleviate skin dryness, promote comfort, and reduce the risk of irritation and skin breakdown.
• Protect bony prominences with foam padding. Prominences have little subcutaneous fat and are prone to breakdown; using foam padding may help promote skin integrity.
• Lift patient's body, whenever required, using a lifting sheet, if needed. Avoid shearing force. Shearing force results when tissues slide against each other; a lifting sheet reduces sliding.
• Keep linen dry, clean, and free from wrinkles or crumbs. Change wet bed linens and incontinence pads immediately. Dry, smooth linens help prevent excoriation and skin breakdown.
• Monitor nutritional intake; maintain adequate hydration. Anemia (<10 mg hemoglobin) and low serum albumin concentrations (<2 mg) are associated with the development of pressure ulcers. Hydration helps maintain skin integrity.
• Use a risk assessment tool such as the Braden Scale to continually assess risk as patient's condition changes. Systematic monitoring helps to identify problems early.
• Change patient's position at least every 2 hours; follow turning schedule posted at bedside. Monitor frequency of turning. These measures reduce pressure on tissues, promote circulation, and help prevent skin breakdown.
• Indicate the risk factor potential on patient's chart and care plan, and reevaluate weekly, using an accepted form such as the Braden Scale. The risk factor score helps evaluate treatment progress.
• Explain the importance of practicing preventive skin care measures to encourage compliance with skin care regimen.
• Supervise patient and patient's family in preventive skin care measures. Give constructive feedback. Practice helps improve skill in managing the skin care regimen.

Suggested NIC Interventions

• Patient's skin remains intact.
• Patient's weight remains within established limits.
• Patient maintains adequate hydration.
• Patient maintains adequate circulation to skin.
• Patient lists preventive skin care measures.
• Patient and family members demonstrate skin care measures.
• Patient and family members understand need to avoid prolonged pressure, obtain adequate nutrition, prevent incontinence, and consistently perform skin care measures.

• Nutritional screening
• Pressure ulcer prevention plan
• Braden or other skin assessment index
• Application of barrier creams and peri care
• Use of pressure redistribution devices
• Repositioning and frequency
• Education for the patient and family regarding pressure ulcer prevention and treatment

• Ahtiala, M., Soppi, E., & Tallgren, M. (2018). Specific risk factors for pressure ulcer development in adult critical care patients—A retrospective cohort study. EWMA Journal, 19(1), 35-42.
• Aloweni, F., Ang, S. Y., Fook, C. S., Agus, N., Yong, P., Goh, M. M., … Soh, R. C. (2019). A prediction tool for hospital-acquired pressure ulcers among surgical patients: Surgical pressure ulcer risk score. International Wound Journal, 16(1), 164-175. doi:10.1111/iwj.13007
• Deng, X., Yu, T., & Hu, A. (2017). Predicting the risk for hospital-acquired pressure ulcers in critical care patients. Critical Care Nurse, 37(4), e1-e11. doi:10.4037/ccn2017548
• National Pressure Ulcer Advisory Panel. (2007). Updated pressure ulcer stages. Retrieved from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations.
• Patton, D., Moore, Z., O'Connor, T., Shanley, E., De Oliveira, A. L., Vitoriano, A., … Nugent, L. E. (2018). Using technology to advance pressure ulcer risk assessment and self-care: Challenges and potential benefits. EWMA Journal, 19(2), 23-27.