Managing Skin Integrity

Required Tools and Resources

• Braden Scale assessment tool
• Institutional pressure injury prevention protocol
• Appropriate support surfaces based on risk level
• Skin care products: barrier cream, moisture wicking pads, adhesive removers
• Repositioning aids: pillows, wedges, heel suspension devices

Step 1 — Perform Braden Scale Assessment

Score each of the six subscales (each scored 1–4, except friction/shear scored 1–3):

1. Sensory Perception (ability to respond to pressure-related discomfort)

• 1 = Completely limited: unresponsive to painful stimuli
• 2 = Very limited: responds only to painful stimuli; cannot communicate discomfort except by moaning/restlessness
• 3 = Slightly limited: responds to verbal commands but cannot always communicate discomfort
• 4 = No impairment: responds to verbal commands; has no sensory deficit

2. Moisture (degree to which skin is exposed to moisture)

• 1 = Constantly moist: skin is kept moist almost constantly
• 2 = Very moist: skin often but not always moist; linen changed at least once per shift
• 3 = Occasionally moist: skin occasionally moist; linen changed approximately once per day
• 4 = Rarely moist: skin usually dry; linen requires changing only at routine intervals

3. Activity (degree of physical activity)

• 1 = Bedfast: confined to bed
• 2 = Chairfast: severely limited ability to walk; cannot bear own weight
• 3 = Walks occasionally: walks occasionally with or without assistance; spends majority of each shift in bed or chair
• 4 = Walks frequently: walks outside room at least twice per day and inside room at least once every 2 hours

4. Mobility (ability to change and control body position)

• 1 = Completely immobile: does not make even slight changes in body position without assistance
• 2 = Very limited: makes occasional slight changes in body position but unable to make frequent or significant changes independently
• 3 = Slightly limited: makes frequent though slight changes in body position independently
• 4 = No limitations: makes major and frequent changes in position without assistance

5. Nutrition (usual food intake pattern)

• 1 = Very poor: never eats a complete meal; rarely eats more than ⅓ of any food offered; protein intake < 2 servings per day; NPO or clear liquids or IV for > 5 days
• 2 = Probably inadequate: rarely eats a complete meal; generally eats about ½ of food offered; protein intake 3 servings per day; occasionally refuses a meal
• 3 = Adequate: eats over ½ of most meals; eats 4 servings of protein per day; occasionally refuses a meal but usually takes a supplement
• 4 = Excellent: eats most of every meal; never refuses a meal; usually eats 4 or more servings of protein per day

6. Friction and Shear

• 1 = Problem: requires moderate to maximum assistance in moving; complete lifting impossible without sliding against sheets; frequently slides down in bed/chair
• 2 = Potential problem: moves feebly or requires minimum assistance; skin probably slides to some extent during moving
• 3 = No apparent problem: moves in bed and chair independently; has sufficient muscle strength to lift up completely during move

Total Braden Score: range 6–23

Step 2 — Stratify Risk and Determine Prevention Interventions

Risk Levels and Corresponding Interventions

Score 19–23: No Risk

• Standard nursing care
• Reassess per institutional schedule (typically on admission, daily, and with condition change)

Score 15–18: Mild Risk

• All standard interventions PLUS:
• Reposition every 2 hours in bed; every 1 hour in chair
• Moisture management: apply barrier cream, manage incontinence promptly
• Nutritional consult if intake is suboptimal

Score 13–14: Moderate Risk

• All mild risk interventions PLUS:
• Pressure redistribution mattress (foam replacement or overlay)
• Heel offloading (elevate heels free of bed surface using pillow or suspension device)
• Formal nutritional assessment and intervention by dietitian
• Consider specialty bed if multiple risk factors

Score 10–12: High Risk

• All moderate risk interventions PLUS:
• Specialty pressure redistribution surface (alternating pressure, low-air-loss)
• Increase repositioning frequency if tolerated
• Multi-disciplinary team involvement (nursing, dietitian, wound care, PT/OT)
• Small shifts in position between scheduled turns (micro-repositioning)

Score ≤ 9: Very High Risk (Severe Risk)

• All high risk interventions PLUS:
• Specialty bed (low-air-loss or air-fluidized therapy)
• Maximum offloading of ALL bony prominences
• Nutritional supplementation: protein 1.25–1.5 g/kg/day, vitamin C, zinc
• Consider every 1-hour repositioning if not contraindicated
• WOCN consultation

Step 3 — Implement Repositioning Protocol

1. Document a turning schedule with specific positions (left lateral, right lateral, supine, prone if applicable)
2. Use the 30-degree lateral tilt to offload the sacrum and trochanters (full 90-degree side-lying increases trochanter pressure)
3. Elevate head of bed no more than 30 degrees when possible to minimize sacral shear (unless contraindicated by respiratory status)
4. Float heels completely off the bed surface — pillows under calves, not under heels; or use heel suspension devices
5. Avoid positioning directly on bony prominences: sacrum, coccyx, ischial tuberosities, greater trochanters, lateral malleoli, heels, occiput
6. Use lift sheets and mechanical lifts to prevent friction and shear during repositioning
7. Document each repositioning with time, position, and skin condition

Step 4 — Manage Moisture and Incontinence

1. Apply moisture barrier cream (dimethicone-based or zinc oxide-based) to skin at risk for moisture-associated damage
2. Change wet or soiled linens and undergarments immediately
3. Implement a structured toileting schedule for patients with incontinence
4. Consider condom catheter for male patients with urinary incontinence when appropriate
5. Evaluate need for fecal management system for patients with severe diarrhea
6. Differentiate moisture-associated skin damage (MASD) from pressure injury — MASD occurs over non-bony prominences, in skin folds, and in areas exposed to moisture
7. Document continence status, interventions, and skin condition at each assessment

Step 5 — Address Nutritional Deficiencies

1. Request dietitian consultation for all patients with Braden nutrition subscale ≤ 2 or total Braden ≤ 18
2. Target protein intake: 1.25–1.5 g/kg/day for patients at risk or with existing pressure injuries
3. Supplement: vitamin C 250 mg BID and zinc 220 mg daily per provider order (NPUAP/EPUAP recommendation)
4. Monitor serum albumin (goal > 3.0 g/dL) and prealbumin (goal > 15 mg/dL) as markers of nutritional status
5. Optimize hydration: 30 mL/kg/day unless fluid restricted
6. Document nutritional intake, supplementation, and dietitian recommendations

Step 6 — Inspect Skin Under and Around Medical Devices

1. Assess skin under ALL medical devices at least every 12 hours (more frequently for high-risk patients):
   • Endotracheal tube tape/securement device
   • Nasal cannula tubing behind ears
   • Cervical collar (occipital, chin, clavicle)
   • CPAP/BiPAP mask
   • Sequential compression devices
   • Pulse oximeter probe
   • Splints and orthopedic devices
   • Urinary catheter (securement site, meatus)
2. Reposition devices when possible to relieve pressure
3. Pad under medical devices where feasible
4. Document device-related skin assessment findings per institutional protocol

Step 7 — Document Skin Integrity Management

1. Braden Scale score: total and subscale scores with date and time
2. Risk level: classification based on total score
3. Prevention interventions: all interventions implemented, matched to risk level
4. Repositioning: each turn documented with time and position
5. Skin assessment: comprehensive skin assessment per institutional frequency
6. Any skin breakdown: described per NPUAP staging with wound documentation (reference managing-wound-assessment-nursing skill)
7. Present-on-admission (POA): ALL existing skin breakdown documented within 24 hours of admission with detailed description

Checkpoint B — Skin Integrity Program Review

Per-Assessment Verification

• Braden Scale scored completely (all 6 subscales)
• Prevention interventions match the risk level
• Repositioning schedule being followed and documented
• Medical device-related skin assessment completed
• Moisture management interventions in place
• Nutritional intervention initiated for at-risk patients

Present-on-Admission Verification

• All pre-existing skin breakdown documented within 24 hours of admission
• POA documentation includes location, size, stage, and detailed description
• Photographs taken per institutional policy with patient consent
• POA status communicated to charge nurse, provider, and wound care team

Quality Audit

• Braden Scale assessed per institutional frequency (admission, daily, and with significant condition change)
• Prevention interventions implemented per risk-stratified protocol
• Repositioning documented per schedule (every 2 hours or more frequently per risk level)
• Heel offloading in place for all bed-bound patients
• Appropriate support surface in use based on risk level
• HAPI prevalence tracked per NDNQI quarterly prevalence survey
• POA documentation complete for all admitted patients with skin breakdown
• Zero tolerance for undocumented pressure injuries — any new skin breakdown investigated
• Compliant with CMS Never Event classification for HAPI Stage 3/4/Unstageable
• Compliant with Joint Commission and NPUAP/EPUAP/PPPIA prevention guidelines
• Nutritional optimization documented for all patients with Braden ≤ 18

Guidelines

• NPUAP/EPUAP/PPPIA: International Pressure Injury Prevention and Treatment Guidelines — the primary clinical evidence base for pressure injury prevention and management
• Braden Scale: Validated for use in acute care, long-term care, and home health; reassess with any significant change in condition
• CMS: HAPI Stage 3, 4, and Unstageable are Never Events — no additional reimbursement for associated treatment; POA documentation is mandatory for CMS defense
• Joint Commission: Requires pressure injury risk assessment on admission and per institutional policy
• NDNQI: Pressure injury prevalence (hospital-acquired and community-acquired) reported quarterly; benchmarked against national database
• WOCN Society: Recommends risk-stratified prevention protocols and standardized wound documentation
• Support surfaces: CMS defines Group 1 (static), Group 2 (dynamic), and Group 3 (air-fluidized) surfaces with coverage criteria for reimbursement
• Scope of practice: RN performs Braden Scale assessment, implements prevention protocol, and coordinates the skin integrity program; WOCN nurse provides expert consultation for complex cases; LPN/LVN may perform skin assessments and implement repositioning under RN direction
• Medical device-related pressure injuries (MDRPI): The fastest-growing category of hospital-acquired pressure injuries; NPUAP includes device-related injuries in the staging system