Skin Assessment and Decubitus ulcer prevention


Impaired Skin Integrity Assessment

  • pressure ulcers



  • those confined to bed for long periods
  • those with motor or sensory dysfunction
  • patients with muscular atrophy
  • those with reduced tissue b/t bone and skin



  • localized areas of infarcted tissue
  • occur when pressure is applied to skin over time resulting in greater than normal capillary closure pressure.
  • Critically ill pts have lower capillary pressure


Initial signs of pressure sores are:

  • erythema – d/t reactive hyperemia which normally resolves in less than an hour


  • unrelieved pressure results in tissue ischemia or anoxia
  • cutaneous tissue breakdown
  • followed by destruction and necrosis of underlying tissue


Assessment for risk factors:

  1. Immobility
  2. Impaired sensory perception or cognition
  3. Decreased tissue perfusion
  4. Decreased Nutritional Status
  5. Friction and shear forces
  6. Increased moisture
  7. Age-related skin changes



  • Duration of immobility related to pressure sore development
  • weight-bearing bony prominences are most susceptible
  • eg sacrum. Coccyx, tuberosities


Sensory impairment

  • sensory loss
  • decreased consciousness
  • paralysis
  • may not be aware of discomfort associated with prolonged pressure on the skin


Decreased tissue perfusion

  • any condition that reduces circulation and nourishment of the skin and subcutaneous tissues
  • altered peripheral perfusion increases risk
  • eg diabetes, obesity and edema


Altered nutritional status

  • deficiencies
  • anemias – dec blood O2 carrying capacity
  • metabolic disorders
  • low protein levels and neg nitrogen balance cause delayed repair


Friction and shear

  • causes vessels to twist and blood supply to be disrupted
  • occurs when patient slides down in bed


Increased moisture

  • tissue masseration
  • skin irritants
  • increased susceptibility to pressure sores’
  • open skin is invaded by microbes



  • have decreased epidermal layer
  • decreased tissue perfusion
  • decreased sweat gland activity
  • diminished sensory perception


Assess for pressure sore development

  1. Assess total skin condition BID
  2. Inspect each pressure site for erythema
  3. Assess erythematous site for blanching response
  4. palpate skin for increased warmth
  5. Inspect for dry, moist skin and breaks
  6. note drainage and odor
  7. evaluate level of mobility
  8. note restrictive devices – splints and restraints
  9. evaluate circulatory statusperipheral pulses and edema
  10. Assess neurovascular status
  11. determine presence of incontinence
  12. evaluate nutritional and hydration status
  13. review patient’s record – Hb, electrolytes, albumin, transferrin and creatinine

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