Home > RNJ > 2005 > May/June > Pressure Sore and Skin Tear Prevention and Treatment During a 10-Month Program

Pressure Sore and Skin Tear Prevention and Treatment During a 10-Month Program
Barbara Brillhart, PhD RN CRRN FNP-C

This article reports the results of a 10-month skin care program for 30 clients on a residential Alzheimer’s disease unit. The majority (n = 26) of the clients were free of pressure sores and skin tears through preventive care during this study. Four clients with Stage I pressure sores and/or skin tears were successfully identified by consistent assessment and healed quickly due to rapidly initiated treatments. This skin care program’s success was attributed to consistent education, preventive care, assessment, documentation, and treatment executed by the entire care team under the leadership of nurse practitioners, one of whom was certified as a rehabilitation nurse.

Assessment, prevention, and treatment of pressure sores and skin tears are important responsibilities of rehabilitation nurses. Pressure sores and skin tears are major healthcare problems, especially for elderly and disabled people. Pressure sores and skin tears can result in extended hospitalization, increased medical and surgical costs, and pain and disfigurement. Pressure sores affect 1 million persons in acute care and nursing home settings. Seeley, Jensen, and Hutcherson (1999) and Mozes (2000) reported that prevalence of pressure sores ranges between 3.5% and 29% in acute care hospital settings, 2.4%–26% in long-term care facilities, and 10%–12.9% in home care. Kaufman (2000) estimated that 1.5 million patients will develop pressure sores each year, at a healthcare cost of $5 billion. Beckrich and Aronovitch (1999) estimated a cost of between $5 billion and $8.5 billion to treat some 1 million to 1.7 million pressure sores each year; in addition, hospitalization will last 2–5 times longer for patients with pressure sores. The cost of treatment for one pressure sore ranges from $2,000 to $30,000 (Olson et al., 1996). Thomas, Goode, LaMaster, Tennyson, and Parnell (1999) cite that 1.5 million skin tears occur annually among adults in institutions.

A pressure sore is an area of soft tissue necrosis resulting from compression of tissue between bone and external surfaces. Pressure sores are classified by four stages based on severity. Stage I pressure sores (superficial skin layer) are characterized by areas of erythema progressing to dusky, blue-gray colors, swelling, and discomfort. Stage II pressure sores (partial-thickness loss of dermis) exhibit skin breakdown, abrasions, blisters, shallow craters, edema, sore drainage, and possible infection. Stage III pressure sores (full-thickness damage) are characterized by extension into the subcutaneous tissue, necrosis and drainage, and local infection. Stage IV pressure sores (full-thickness damage involving fascia, muscle, and bone) are characterized by extension into underlying muscle and bone, deep pockets of infection, necrosis, and drainage (Stotts & Cavanaugh, 1999). At high risk for pressure sores include those older than 70 years of age, and those who are immobile, malnourished, and incontinent.

Skin tears are traumatic wounds that result from friction alone or shearing plus friction. The epidermis is separated from the dermis, or the epidermis and dermis layers separate from underlying tissues. A Category I skin tear occurs without tissue loss (epidermis and dermis separate), and may involve a linear or flap tear. Category II skin tears are characterized by partial epidermis tissue loss ranging from less than 25% (minor) to higher percentages (moderate). Category III skin tears are characterized by the absence of the epidermal flap. Those at risk for skin tears typically are the elderly, with loss of subcutaneous fat, impaired vision, stiffness, spasticity, sensory loss, bruising, and immobility. Those who use assistive devices also are at risk. Skin tears have been associated with wheelchair injuries (25%), bumps into objects (25%), transfers (18%), and falls (12.4%) (Baranoski, 2000).

Purpose of the Project

The purpose of this project was to investigate the effectiveness of a skin care program for the prevention, assessment, and treatment of pressure sores and/or skin tears for clients on a residential Alzheimer’s disease unit.

Literature Review

One program using the Agency for Health Care Policy and Research (AHCPR) guidelines found that education on skin programs was more effective with repeated programs using multiple formats (McNees, Braden, Bergstrom, & Ovington, 1998). The guidelines identify those with risk factors for pressure, use of risk assessment scales, and development of institutional treatment protocols based on research. Education was most effective if content was updated frequently and presented to the team responsible for skin care.

Frantz, Gardner, Specht, and McIntire (2001) conducted a study to determine if research-based pressure sore treatments had been implemented over time in a long-term care facility. Chart review over 1 year after initiation of a pressure sore protocol targeted those with Stages II, III, or IV pressure sores. Data analysis revealed 46 pressure sores, 40 (87%) of which had healed. The cost for treating the pressure sores was $18,688, with 80% of the primary costs going toward nursing care. Analysis also revealed that nurses followed the research-based treatment protocols.

A 6-month study was conducted in a Veteran’s Administration nursing home unit and in nine community nursing homes to determine risk factors for skin tears (McGough-Csarny & Kopac, 1998). Data indicated that those at high risk for skin tears were very old, frail patients. Other risk factors were dependency for activities of daily living, dementia, poor nutritional status, stiffness, spasticity, sensory loss, prior skin tears, polypharmacy, use of assistive devices, and the presence of ecchymosis. Skin tears, which occurred most often on upper extremities, were Category I tears.

Strayer and Martucci (1997) discussed a skin care program developed by an interdisciplinary team of healthcare workers. The responsibilities of the team were to assess, document, treat, and evaluate using a wound management program. An interdisciplinary committee comprising physicians, nurses, and physical therapists were on staff in a 75-bed rehabilitation facility and a 135-bed long-term care facility for adolescents and adults. The committee developed protocols to assess and document wound status with a flow sheet and photographs. They also developed a treatment manual that addressed each pressure sore stage, and continued to refine and develop standards based on practice and research.

Pressure sore assessment involves the entire person, not just the wound (van Rijswijk & Braden, 1999; Stotts & Cavanaugh, 1999). Assessments should include the location, depth/staging, sinus tracts/tunneling/undermining, exudates, necrotic tissue, and granulation status. A complete assessment also includes a history and physical examination and a nutritional status and pain level evaluation. Assessments should be scheduled at least weekly to accommodate treatment plan revisions.

The ideal treatment guidelines are based on clinical trials (van Rijswijk, 1999). Van Rijswijk recommended the AHCPR guidelines, which address pressure sore treatment. She also says such guidelines should be reviewed periodically and updated to remain relevant to practice.

Many products are needed to treat pressure sores and skin tears. The pressure sore’s stage determines which product to use. Dressings provide optimal healing environments, decrease pain, and act as a barrier. Specific dressings for pressure sores includes hydrocolloids, composite dressings, and hydrogels for Stages I–IV; collagens for Stages III–IV; and gauze dressings for Stage IV. Hydrogen peroxide, povidone-iodine, hypochlorite solutions, or acetic acid, are not recommended because they delay healing (Baranoski, 1999). Stage III and Stage IV pressure sores may require debridement, for which moisture-retaining dressings or hydrogels that encourage enzymatic degradation may be used (Ovington, 1999). Debridement is followed by wound cleansing with whirlpool therapy, saline irrigations, or lavage with suction (Rodeheaver, 1999). Maklebust (1999) advocates pressure relief prevention and treatment measures using foam overlays, air overlays, sheepskin, foam cubes/mattresses, egg crate foam, gel cushions, and/or low-air-loss beds. Buss, Halfens, and Abu-Saad (2002) recommend starting at 2-hour intervals as most effective for repositioning those at risk for pressure sores, and shortening or lengthening that interval to accommodate individual needs.

Thomas, Goode, Lamaster, Tennyson, and Parnell (1999) studied 37 subjects treated for skin tears and compared opaque foam dressings with transparent film dressings. Subjects had either Category II or Category III skin tears. Results revealed that 94% of subjects treated with the foam dressing experienced complete healing, compared with 65% of subjects who were treated with the film dressing.

Baranoski (2000) made practice- and research-based recommendations, including: (a) treat skin tears by gently cleansing the wound with saline, allowing it to dry and then approximating the skin tear flap, (b) apply hydrogel foam or a petroleum-based dressings, (c) use steri-strips to approximate skin edges, (d) avoid dressings with adhesive backings because they can cause further skin trauma, and (e) secure dressings with gauze or tubular nonadhesive wrap.


The theoretical support for this project is Orem’s Self-Care Deficit Conceptual Framework (Orem, 1991). While self-care is the ability to provide basic needs for oneself, dependent self-care is the ability to provide basic needs for a child, an elder, or a disabled person. Healthcare deficits are unmet self-care needs. Therapeutic self-care demands are the specific needs of an individual as a result of disease, illness, or injury. Nurses are responsible for addressing healthcare deficits and therapeutic self-care demands when individuals or families cannot meet their needs.

Nursing is provided at three levels of care. When nurses provide total care for an individual, this is the wholly compensatory level of care. A partly compensatory level of care occurs when nurses and the patient or family each provide partial care. Educational-supportive care occurs when nurses provide education, resources, counseling, and support to enable individual or family self-care (Orem, 1991).

Clients in the residential Alzheimer’s disease unit have therapeutic self-care demands because of their many risk factors for pressure sores and skin tears, which include immobility, incontinence, depressed immune systems, poor circulation, low levels of cognition, decreased sensation, and fragile skin. These patients require a wholly compensatory level of nursing care. The care staff compensates for the clients’ and families’ limitations to meet self-care demands and therapeutic self-care demands.


This skin care program was initiated after one client living in a 30-bed residential Alzheimer’s disease unit developed a Stage IV pressure sore. This unit followed the Arizona Model for Residential Care, involving nurse practitioners who make daily rounds and provide care in collaboration with attending physicians. The Arizona Model for Residential Care includes nonnursing staff as recreational therapists and nonnursing attendants. Medications were administered by medicine technicians or licensed vocational nurses. The focus of care was residential living, not long-term health care. All personnel were committed to preventing pressure sores and skin tears, and rapid initiation of necessary care.

All residents on the unit were in the advanced stages of the Alzheimer’s disease. The focus of this skin care program was prevention. The treatment phase of the program included 2 men and 2 women (mean age 85.75 years) who had Stage I pressure sores and/or skin tears. These four residents had advanced dementia, fragile skin, immobility, incontinence, and instability while balancing/walking. No other similar residents had pressure sores or skin tears during the study period.

The staff education portion of the skin care program focused on the prevention, assessment, and treatment of pressure sores and skin tears. A rehabilitation nurse, who also was a nurse practitioner, presented the skin care program on all shifts every 3 months for a 10-month period. Staff members attending the education program included nonnursing care attendants, licensed vocational nurses, a recreational therapist, and the care unit administrator.

Nonnursing care attendants served as first-line personnel for resident assessment when the clinical portion of the skin care program was established. Any skin condition, including redness, swelling, skin tears, abrasions, or skin breakdown, was reported to nurse practitioners who made daily rounds on the unit. Nurse practitioners used a clear-plastic centimeter-measuring instrument on a daily basis to further assess the width and depth of pressure sores and/or skin tears. Treatment was initiated immediately through the coordinated efforts of physicians, nurse practitioners, and care staff. Family nurse practition- ers, who also made rounds with home health nurses and nonnursing care attendants to assess clients and coordinate care, developed a flow sheet to record descriptions of pressure sores and skin tears and the treatments used (Figure 1). Flow sheets were kept on a colorful clipboard for quick reference during rounds. Care was documented on the flow sheet under the categories of skin treatment, mobility treatment, pressure relief, and medications. Common treatments were labeled by name and assigned a number for efficient chart documentation. Pressure sore and skin tear descriptions also were documented in the charts. The skin care program continued for 10 months until the unit closed.


Education for nonnursing care attendants focused on preventing pressure sores and skin tears. Preventive measures included correct transfer and mobilization techniques to avoid skin trauma from shearing and friction. Prevention also included the use of pressure-relief devices, such as sheepskin placed in chair backs and seats and in beds as overlays. Position changes to relieve pressure were achieved through turning and mobilization. Nonnursing care attendants’ routine included toileting every 2 hours, or changing incontinent clients’ adult diapers every 2 hours to avoid skin irritation. As a result of this preventive care, 26 of 30 clients were free of pressure sores and skin tears throughout the program’s 10-month duration.

Table 1 details results of care for four clients with either pressure sores or skin tears during implementation of the program.


The results of this skin care program reflect success. Although four clients developed either Stage I or Stage II pressure sores, three clients healed completely and experienced no reoccurrence of pressure sores or skin tears. One client with multiple risk factors healed for periods up to 1 month, and never progressed beyond Stage II. None of these four clients required hospitalization or extensive treatment for pressure sores or skin tears.

The educational portion of the skin care program followed the guideline of McNees, Braden, Bergstrom, and Ovington (1998), which recommended frequent reeducation for a ll personnel using differing formats. The educational content was similar to content from Strayer and Martucci (1997), who recommended a team approach to care with detailed documentation. Educational content included lectures on pressure sore and skin tear prevention and assessment, graphics depicting pressure sore stages and skin tear categories, a demonstration of transfer techniques using residential clients with mobility limitations, and suggested schedules for toileting or adult diaper changes. The nurse practitioners reinforced principles of care for nonnursing staff during daily rounds.

Pressure sore and skin tear treatment was the responsibility of the family nurse practitioners caring for all four clients with Stage I pressure sores or skin tears, and of a home health nurse for one client with persistent pressure sores. Treatment was a success, as evidenced by the rapid healing of Stage I pressure sores and skin tears and the absence of Stage III and Stage IV pressure sores throughout the skin care program.

The consistent leadership of the enthusiastic nurses who ensured preventive measures, assessments, and early treatment were in place was essential to this program’s success. The entire staff’s persistent efforts to assess clients on schedule and then communicate concerns to nurse practitioners contributed to the success. The care staff was praised for its accurate assessments, improved transfer/mobility skills, and skin care/cleanliness efforts. It takes a motivated care team to meet the challenges posed by long-term care residents with multiple risk factors for pressure sores and skin tears.


I would like to acknowledge Marianne Murzyn, MSN RN FNP-C, and Colette Toronto, MSN RN FNP-C, family nurse practitioners, and the healthcare team for their efforts with the skin care program. This project was funded by a faculty minigrant from the College of Nursing at Arizona State University in Tempe, AZ.

About the Author

Barbara Brillhart, PhD RN CRRN FNP-C, is an associate professor at the Arizona State University College of Nursing in Tempe, AZ. Address correspondence to her at Arizona State University, College of Nursing, Box 872602, Tempe, AZ 85287-2602, or via e-mail at barbara.brillhart@asu.edu.


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