Definition:

Breakdown in skin primarily due to impaired blood supply as a result of prolonged pressure on the
tissue. Skin integrity may also be broken as a result of shearing or friction injury. The epidermis is
not intact and layers below the skin like the dermis and bone may be visible.

Defining Characteristics:

1) Visible breakdown of skin,

2) exposure of dermal tissue or bone

3) denuded skin that may be accompanied by erythema, edema and discharge

4) the skin breakdown may vary in size

5) the adjacent skin will be fragile and edematous

6) depth of the tissue breakdown not fully assessed visually

7) discharge may vary from serous fluid to foul smelling, if there is an infection.

Related Factors:

1. Functional: Immobility is the primary cause. The constant pressure on bony prominences
eventually leads to breakdown of skin.

2. Psychological: Client may have mental illness, be delirious and may be sedated or restrained for
a prolonged time, which can lead to pressure on skin. Inability to sense pressure or pain is a
common cause of pressure sores or open wounds.

3. Pharmacological: Use of certain drugs like sedative, neuromuscular blockers can lead to
immobility in one position and lead to pressure sore

4. Mechanical: Anything that applies pressure on skin can lead to breakdown. This can be a cast,
splint, physical restraints or poor use of an ambulatory device. Prolonged sleeping or sitting in one
position is probably the most common cause of skin breakdown. Client may also have severe
itching, which can lead to excoriations and breakdown of skin. A stoma may be poorly functioning
and lead to leakage of fecal material on skin

5. Physiological: Poor dietary habits; diminished appetite, inadequate dentition; insufficient fluid
intake; and dehydration can prevent wounds from healing

Nursing Outcomes
1. Improved appetite and nutrition

2. Turn patient every few hours to prevent constant pressure

3. Healing of skin

4. Absence of inflammation such as redness, swelling and edema

5. Properly functioning stoma

6. Adequate hydration

7. Regaining mobility

Nursing interventions and rationale for each intervention

1. Assess client’s risk of skin breakdown on admission using the available risk assessment tools
like the Braden and Knoll assessment scale.

2. Physically examine the skin. Assess the high-risk areas like bony prominences (elbows, sacrum,
heels). The skin should be examined for redness, pallor, edema and open sore. Photos should be
obtained to prevent potential litigation.

3. If skin impairment is present, it must be staged.

4. Monitor for signs of infection like pain, fever, foul discharge, redness or pus collection .