Skyrocketing health care expenses and the demand for more cost-effective health care have

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1 Feature The Healthy Skin Project: Changing Nursing Practice to Prevent and Treat Hospital-Acquired Pressure Ulcers Teri Armour-Burton, RN, MSN, MBA, CNML, NE-BC Willa Fields, RN, DNSc Lanie Outlaw, RN, BSN, PCCN Elvira Deleon, RN, BSN BACKGROUND Hospital-acquired pressure ulcers are serious clinical complications that can lead to increased length of stay, pain, infection, and, potentially, death. The surgical progressive care unit at Sharp Grossmont Hospital, San Diego, California, developed the multidisciplinary Healthy Skin Project to decrease the prevalence of hospital-acquired pressure ulcers. METHODS The previous treatment plan was reviewed and modified according to current evidence-based practice. The project consisted of 3 components: creation of a position for a unit-based wound liaison nurse, staff education, and involvement of the nursing assistants. The wound liaison nurse developed and conducted bimonthly skin audits, which revealed inconsistencies in clinical practice and documentation. Education for the staff was accomplished via a self-learning module, case presentations, and 1-on-1 training. In addition, a pressure ulcer algorithm tool was developed to demonstrate step-by-step wound management and documentation. RESULTS From Spring 2003 through Summer 2006, the prevalence of hospital-acquired pressure ulcers ranged from 0.0% to 18.92%, with a mean of 4.85%. After implementation of the project, the prevalence decreased to 0.0% for 17 of 20 quarters, through CONCLUSION Prevention and a multidisciplinary approach are effective in reducing the occurrence of hospital-acquired pressure ulcers. (Critical Care Nurse. 2013;33[3]:32-40) Skyrocketing health care expenses and the demand for more cost-effective health care have forced nurses to constantly examine the methods by which quality patient care is provided. Preventing hospital-acquired pressure ulcers (HAPUs) has become a health care priority, especially since October 1, 2008, when the Centers for Medicare and Medicaid Services ceased providing payment for certain hospital-acquired conditions, including stage III and stage IV pressure ulcers. 1 In 2007, the Centers for Medicare and Medicaid Services reported cases of pressure ulcers as a secondary diagnosis. 2 The mean cost for treating a patient with a secondary diagnosis of pressure ulcer was $ The impact of HAPUs goes beyond dollars and may also include prolonged hospitalization, pain, infection, and, potentially, death American Association of Critical-Care Nurses doi: 32 CriticalCareNurse Vol 33, No. 3, JUNE

2 20 15 Prevalence, % Year Figure 1 Prevalence of pressure ulcers acquired in progressive care unit. The Agency for Healthcare Research and Quality reported that the incidence of patients with both a primary and a secondary diagnosis of pressure ulcers increased by 80% between 1993 and Individual performanceimprovement projects have been effective in reducing the incidence of HAPUs. 4 Chicano and Drolshagen 5 reported that implementation of a performance-improvement project resulted in a decrease in the incidence of HAPUs from 5% to 0% during 2 consecutive 1-year periods. In response to the payment practices of the Centers for Medicare and Medicaid Services, published reports of successes in reducing HAPUs, increasing costs, and quarterly prevalence of HAPUs, the practice council of Authors Teri Armour-Burton is a nurse manager at Sharp Grossmont Hospital, La Mesa, California. Willa Fields is a professor in the graduate leadership concentration at San Diego State University, California, and a program manager at Sharp Grossmont Hospital. Lanie Outlaw is a clinical nurse in a surgical progressive care unit at Sharp Grossmont Hospital. Elvira Deleon is a clinical nurse in a surgical progressive care unit at Sharp Grossmont Hospital. Corresponding author: Teri Armour-Burton, RN, BSN, MSN, MBA, CNML, NE-BC, Sharp Grossmont Hospital, 5555 Grossmont Center Dr, La Mesa, CA ( teri.armour-burton@sharp.com). To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. the progressive care unit (PCU) at Sharp Grossmont Hospital, San Diego, California, embarked on the Healthy Skin Project. The purpose of the project was to reduce the prevalence of HAPUs. Background The PCU is a 41-bed unit with a mean daily census of 36 patients, mean length of stay of 4.2 days, and approximately 10 discharges or admissions per day. Most of the patients have cardiac, pulmonary, and renal illnesses. The unit is staffed by 65 registered nurses and 20 nurse assistants, who have been working in health care between 6 months and 30 years. From Spring 2003 through Summer 2006, the prevalence of HAPUs in the unit ranged from 0.0% to 18.92%, with a mean of 4.85%. Not only was the prevalence of HAPUs increasing, but in some quarters the rate was greater than the benchmark of the Collaborative Alliance for Nursing Outcomes, which ranged from 3.61% to 11.44% for the same period (Figure 1). Nursing Practice Before Implementation of the Project Before implementation of the project, preventing pressure ulcers was guided by each patient s primary nurse and relied on the nurse s preexisting knowledge and experience of the assessment and treatment of skin problems. The primary nurse completed a skin assessment CriticalCareNurse Vol 33, No. 3, JUNE

3 and determined the patient s Braden Scale classification once a shift. The Braden Scale 6,7 is a tool widely used to assess a patient s risk for pressure ulcers. The Braden Scale is based on 6 different indicators: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Scores for the sensory perception, moisture, activity, mobility, and nutrition sections range from 1 to 4. Scores for the friction and shear section are from 1 to 3. The higher the score for each indicator, the lower is the risk for skin breakdown. A total score of 15 to 18 indicates a risk for pressure ulcers, 13 to 14 indicates moderate risk, 10 to 12 indicates high risk, and 9 or less indicates very high risk. The Braden Scale has 0.81 validity (area under the receiver operating curve) for predicting the development of pressure ulcers, with a cutoff score of 17 in long-term care. 8 Interrater reliability in critical care has been reported as 0.72 and 0.84 (intraclass correlation coefficients), with 95% confidence intervals of 0.52 to 0.87 and 0.72 to 0.92, respectively. 9 On the basis of these results, the Braden Scale is valid and reliable for identifying patients in multiple settings who are at risk for pressure ulcers. Once the Braden Scale classification and skin assessment were completed in the PCU, the findings were documented in the electronic medical record. Using the information Before implementation of the Healthy gathered during the skin Skin Project, the approach to treating skin breakdown was reactive and curative rather than proactive and preventive. the nurse assessment, would then determine a treatment plan and would consult the wound team if the patient had either a nonhealing wound or marked skin breakdown. A digital image of the skin breakdown was uploaded to the electronic medical record and was used to provide a visual record. The final step was to complete an event report to record the details and track the occurrence of skin breakdown. The staff members approach to treating skin breakdown was reactive and curative rather than proactive and preventive. The Healthy Skin Project The Healthy Skin Project began in 2005 and was fully implemented by late The project consisted of 3 components: creation of a position for a unit-based wound liaison nurse, staff education, and involvement of the nursing assistants in the prevention of HAPUs. Wound Liaison Nurse The wound liaison nurse was a unit-based staff nurse who devoted approximately 24 hours per month to the role. This nurse had advanced knowledge in caring for patients with compromised skin. She enhanced her baseline knowledge of identifying skin breakdown, staging pressure ulcers, and implementing treatment strategies by attending educational seminars on skin care, participating in skin assessment rounds with the wound team department nurses, and completing courses on proper staging and treatment of pressure ulcers. To help guide the process, the wound liaison nurse consulted with a nurse certified as a wound, ostomy, and continence nurse who was a member of the hospital-based wound team. The wound team provided additional information on wound staging, treatment plans, and documentation. The wound liaison nurse analyzed current skin practices to guide the plan to improve skin care and decrease HAPU prevalence. To identify opportunities to improve practice, the she performed bimonthly audits of all patients admitted to the unit. The data were collected and recorded on an audit tool (Table 1) for comparisons and determination of trends. As part of the bimonthly audit, the wound liaison nurse verified that the required components of the skin care plan were implemented and updated every 24 hours. The skin care plan (Table 2), an existing hospitalwide computerized plan of care, contained a treatment plan for patients who were at risk for pressure ulcers or who had actual skin breakdown. The plan included recommendations for therapeutic support surfaces, linen usage, turning schedule, skin care products, and recommended s. As a patient s skin status changed, unit nurses modified the skin care plan. Skin documentation, completed on admission and once a shift, included results of the skin assessment. The skin assessment included determining a Braden score and describing the patient s skin integrity, color, temperature, and turgor. Additional digital images were acquired if the pressure ulcer worsened and when the patient was discharged. For stage III and stage IV ulcers, digital images were also acquired to document improvement in skin integrity. For patients with documented pressure ulcers, the wound liaison nurse performed a physical assessment and compared the findings with the patient s skin documentation and digital image. Any discrepancies detected 34 CriticalCareNurse Vol 33, No. 3, JUNE

4 Date Table 1 Skin assessment audit tool Room Braden score Skin visually assessed Skin IPOC started Pressure ulcer location Pressure ulcer stage Measurement taken Picture taken Skin team consulted Treatment plan started Event report completed Hospital acquired? Abbreviation: IPOC, interdisciplinary plan of care. Table 2 Skin care plan Skin tears Cleanse with physiological saline Close approximate edges Cover with nonadherent dressing and gauze roll Change dressings daily and as needed Pressure ulcers Stage I Stage II Stage III or IV Elevate heels off bed Turn patient every 2 hours Lesion with intact blister: Position patient off affected area Lesion shallow and moist: Cover with 1 layer of nonadherent gauze dressing, secure, and change daily Lesion shallow and dry: Cover with 3 layers of nonadherent gauze dressing, secure, and change daily Notify physician Wet lesion: Cover with multiple layers of gauze, secure, and change daily Dry lesion: Cover with multiple layers of nonadherent gauze, secure, and change daily Unstageable necrotic tissue Notify physician Dry eschar Cover with multiple layers of nonadherent gauze, secure, and change daily Deep tissue injury Notify physician Elevate heels off bed during this comparison were reviewed with the staff member who charted the original findings. Whenever a pressure ulcer was discovered, on admission or during hospitalization, an event report was generated. The wound liaison nurse reviewed all event reports and ensured that each report included each patient s demographics, wound measurements, wound staging, site of the lesion, and the treatment. The event report did not include a digital image of the pressure ulcer. The event reports were used to track the occurrence of pressure ulcers and the nursing actions used to start treatment. A pressure ulcer was considered hospital acquired if its existence was not detected via the documentation process within 24 hours of admission to the PCU. This 24-hour window for reporting was developed in response CriticalCareNurse Vol 33, No. 3, JUNE

5 to the present-on-admission reporting guidelines of the International Classification of Diseases, Tenth Revision, Clinical Modification. 10 The wound liaison nurse reviewed current and previous clinical records of patients with pressure ulcers and shared the findings during unit-based staff meetings to determine how current practices could be modified to improve staff compliance with unit guidelines for skin care. The results of the clinical record reviews and input gathered during staff meetings were shared with the PCU practice council for further analysis. Analysis revealed several important factors that were contributing to a high prevalence of HAPUs. These factors included lack of comprehensive skin assessment upon admission, absence of an event report and image note for patients who had pressure ulcers at the time of admission, inconsistent and Small caricatures of infants were used as inaccurate visual cues at the bedsides of patients measurements who required skin precautions, to illustrate the delicacy of the patients skin. ulcers, incom- of pressure plete Braden Scale scoring, and inconsistencies in the treatment plan for patients with pressure ulcers. The wound liaison nurse and the PCU practice council worked on developing evidence-based changes in practice that would improve patients outcomes. Staff Education Before the Healthy Skin Project, staff nurses received brief, unstructured training on skin care and management of patients with skin lesions. For example, during a nurse s orientation, preceptors discussed treatment for pressure ulcers when such ulcers were discovered in the patients assigned to the nurse for care. The unit had no organized, structured education for skin care or HAPU prevention. A major strategy used during the Healthy Skin Project was to provide comprehensive evidence-based education and training to staff nurses on the assessment, prevention, and staging of skin lesions and on possible treatment options. 10,11 The revised educational plan included a variety of teaching strategies: a skin education manual, poster boards, presentation of case studies, and a skin care algorithm. The wound liaison nurse, in with the hospital wound team, compiled a 3-part, self-learning, 30-page educational manual on skin care. The first 2 parts contained actual photographs of pressure ulcers, other skin lesions in various stages, 11 and possible treatment plans. Each photograph was accompanied by information on wound staging, descriptions, and measurement techniques. The final section contained a 30-item test that was used to evaluate each staff member s ability to identify skin lesions and to develop treatment plans. Staff members reported that it took approximately 30 to 45 minutes to complete the self-learning manual and an additional 15 to 30 minutes to complete the test. The test was used to provide an evaluation of learning. Each test question contained a photograph of a pressure ulcer or skin lesion that staff members were asked to stage and provide a course of treatment for. Current staff members completed the self-learning manual on a volunteer basis. In order to encourage participation, all staff members who successfully completed the test with a passing score of 90% or better were awarded a certificate of completion, and their names were entered into a prize drawing. In addition, current staff nurses were required to complete the self-learning manual if monthly audits revealed that the nurses had misstaged or inaccurately measured a pressure ulcer. For all new staff members, successful completion of the self-learning manual (ie, a score of at least 90%) was mandatory. Any items answered incorrectly were reviewed with the wound liaison nurse. Posters of skin care products were created in collaboration with the wound team and were posted in highly visible areas throughout the PCU. These posters contained actual product samples, order information, and clinical indications for each product. Staff members used the poster boards as a reference to ensure that the appropriate products were used to treat skin lesions. The wound liaison nurse, in conjunction with the hospital-based wound team, continuously evaluated and updated the information on the posters to ensure that the latest and most appropriate product information was available. Patients who had pressure ulcers at the time of admission that were difficult to stage or treat were presented as case studies during monthly staff meetings. The wound liaison nurse directed the interactive case study presentations. The presentations provided an opportunity for the staff to exchange information on wound staging, pressure ulcer treatment, and nursing documentation. A summary of the case studies was posted on the staff educationtraining board for further review and evaluation. 36 CriticalCareNurse Vol 33, No. 3, JUNE

6 Patient Nurse Visual skin assessment On admission Every shift Pressure ulcer Braden Scale On admission Every shift Potential pressure ulcer Obtain digital image Take measurement (in centimeters) Event report/calnoc Document Skin IPOC Nurse s note Wound flowsheet Complete pressure ulcer checkoff list Skin care liaison for question Unavoidable development of pressure ulcer Implement preventive measures Skin hygiene Prevent pressure Improve nutrition Document Skin IPOC Nurse s notes Consultations Physician Wound team Dietitian Start treatments Mattress Skin barriers Dressings Discharge planner family involvement Nursing assistants Assist nurse in implementing preventive measures Inform nurse of any changes or any new skin issues Shift report Documentation Treatment flowsheet Figure 2 Algorithm for pressure ulcer management. Abbreviations: CALNOC, Collaborative Alliance for Nursing Outcomes; IPOC, interdisciplinary plan of care. A multidisciplinary evidence-based pressure ulcer algorithm 12,13 was developed to guide wound management (Figure 2). The algorithm provided direction for treating both patients who had pressure ulcers and patients who were at risk for such ulcers. The algorithm included steps a patient s nurse and other team members should take from admission to discharge. Depending on a patient s degree of skin breakdown, the algorithm prompted the primary nurse to review the patient s skin hygiene program. The skin hygiene program ranged from increasing the frequency of perineum care to application of barrier products. The algorithm also served as a guide for appropriate skin assessment and documentation. Finally, the algorithm was useful in making decisions about when to request s from other health care disciplines. After completing a comprehensive assessment, a patient s primary nurse determined if a request should be made for with the wound team, nutritional services, or surgical services. If the patient had skin breakdown at the time of admission or if skin breakdown developed after admission, the nurse triggered with the wound team via the electronic health record. The wound team then performed a secondary assessment and prescribed a plan. The initial and daily assessments included an evaluation of a patient s nutritional status. If the patient did not eat at least 50% of his CriticalCareNurse Vol 33, No. 3, JUNE

7 or her meals, the primary nurse discussed the findings with the patient s health care provider, and with nutritional services was ordered. Finally, for patients with nonhealing, deep-tissue wounds that had no indications of improvement, the nurse, in conjunction with the wound team, consulted with the health care provider, and with surgical services was ordered for further evaluation. Nursing Assistants A major change in practice was including the nurse assistants in the treatment and management of pressure ulcers. During meetings with the nurse assistants, the wound liaison nurse presented information on how to identify reddened skin, the importance of reporting reddened skin to a patient s nurse, proper linen use (eg, no linen layering or diapers), the patient s turning schedule, and skin hygiene. This new practice of including the nurse assistants led to improved continuity of care and enhanced teamwork. Now nurse assistants were expected to visualize the condition of a patient s skin and report any indications of skin Including the nurse assistants in the Healthy Skin Project allowed for early breakdown or detection and was the final step in creating a multidisciplinary team approach. patient s redness to the nurse. The patient s nurse then conducted a comprehensive skin assessment to determine if the patient was at risk for skin breakdown and implemented skin precautions as needed. Skin precautions indicated that the patient s skin integrity had been compromised and that a specific treatment plan had been activated to prevent further skin breakdown. If a patient s nurse determined that the patient required skin precautions, visual cues were placed at the patient s bedside. Staff members decided to use small caricatures of infants to illustrate the delicacy of the patient s skin condition. These cues were intended to alerted the staff that the patient s skin was delicate. The visual cues also served as a reminder of the project goal of achieving healthy skin. These visual cues prompted the nurse assistants to ensure that a patient s position was changed at least and verified that the proper amount and type of linens were used on the patient s bed. In order to monitor each patient s turning schedule, a 24-hour turning log was placed in each patient s room. A nurse assistant documented that the patient was being turned appropriately and on schedule by initialing each hour s slot. The patient s primary nurse used the 24-hour log in conjunction with ongoing visual inspections to determine if the turning schedule was adequate and made any necessary adjustments. Finally, patients with skin breakdown were placed on pressure-reducing mattresses. The nurse assistants were asked to perform daily inspections to ensure that the patients were on the prescribed mattresses. Early detection and prevention are important elements in treating pressure ulcers. Including the nurse assistants in the Healthy Skin Project allowed for early detection and was the final step in creating a multidisciplinary team approach. Results After full implementation of the Healthy Skin Project in late 2006, the prevalence of HAPUs was 0.0% for 17 of 20 quarters, through For quarters 1 and 2 of 2008 and quarter 2 of 2011, the prevalences were 2.50%, 3.33%, and 2.94%, respectively (Figure 1). This increase in prevalence was a result of incomplete baseline documentation on patients who had preexisting pressure ulcers at the time of admission, as required by the Centers for Medicare and Medicaid Services. Moving Forward Additional steps have been taken to ensure that the Healthy Skin Project continues to create positive patient outcomes. A night shift wound liaison nurse has been added to ensure 24-hour support for the project. The wound liaison nurses perform ongoing monthly audits to evaluate staff compliance and identify any educational opportunities. The results of the monthly audits are disseminated to staff members during staff meetings and are posted on the unit for review. In addition, the wound liaison nurses, in conjunction with the wound, ostomy, and continence nurses, continue to conduct literature reviews and product evaluations to ensure that skin breakdown is treated in compliance with the most current evidence-based practice. All new staff nurses are trained and educated on the identification, documentation and treatment of skin breakdown. Staff members have embraced the practice changes and have joined to make the Healthy Skin Project a continued success. CCN Financial Disclosures None reported. 38 CriticalCareNurse Vol 33, No. 3, JUNE

8 Now that you ve read the article, create or contribute to an online discussion about this topic using eletters. Just visit and click Submit a response in either the full-text or PDF view of the article. To learn more about caring for patients with pressure ulcers, read Protecting Fragile Skin: Nursing Interventions to Decrease Development of Pressure Ulcers in Pediatric Intensive Care by Schindler et al in the American Journal of Critical Care, January 2011;20: Available at References 1. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals: fact sheet. Published October Accessed March 19, Department of Health and Human Services, Centers for Medicare and Medicaid Services, Medicare Program; proposed changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; proposed changes to disclosure of physician ownership in hospitals and physician self-referral rules; proposed collection of information regarding financial relationships between hospitals and physicians proposed rule. Fed Reg. 2008;73(84): /2008/pdf/ pdf. Accessed March 19, Russo CA, Steiner C, Spector W. Statistical Brief #64: Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, Agency for Healthcare Research and Quality. Accessed April 1, Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission (POA) indicators/ hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel. J Wound Ostomy Continence Nurs. 2008;35(5): Chicano SG, Drolshagen C. Reducing hospital-acquired pressure ulcers. J Wound Ostomy Continence Nurs. 2009;36(1): Braden BJ, Bergstrom N. Clinical utility of the Braden Scale for predicting pressure sore risk. Decubitus. 1989;2(3):44-46, Braden Scale. Accessed March 19, de Souza DM, Santos VL, Iri HK, Sadasue Oguri MY. Predictive validity of the Braden Scale for pressure ulcer risk in elderly residents of longterm care facilities. Geriatr Nurs. 2010;31(2): Kottner J, Dassen T. Pressure ulcer risk assessment in critical care: interrater reliability and validity studies of the Braden and Waterlow scales and subjective ratings in two intensive care units. Int J Nurs Stud. 2010; 47(6): US Department of Health and Human Services, Centers for Medicare and Medicaid Services and the National Center for Health Statistics. Appendix I: present on admission reporting guidelines. In: ICD-9-CM Official Guidelines for Coding and Reporting. 2011: Accessed March 19, National Pressure Ulcer Advisory Panel. Resources. Accessed March 20, Wound, Ostomy, and Continence Nurses Society. Guidelines for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy, and Continence Nurses Society; Updated September 28, Accessed March 20, Ayello EA, Lyder CH. Protecting patients from harm: preventing pressure ulcers in hospital patients. Nursing. 2007:37(10): CriticalCareNurse Vol 33, No. 3, JUNE

9 CCN Fast Facts CriticalCareNurse The journal for high acuity, progressive, and critical care nursing The Healthy Skin Project: Changing Nursing Practice to Prevent and Treat Hospital-Acquired Pressure Ulcers Facts Hospital-acquired pressure ulcers (HAPUs) are serious clinical complications that can lead to increased length of stay, pain, infection, and death. The surgical progressive care unit (PCU) at Sharp Grossmont Hospital developed the multidisciplinary Healthy Skin Project to decrease the prevalence of HAPUs. This project consisted of 3 components: a unit-based wound liaison nurse, staff education, and involvement of the nursing assistants in the prevention of HAPUs. Wound Liaison Nurse The wound liaison nurse was a unit-based staff nurse who devoted about 24 hours per month to the role. This nurse verified that the required components of the skin care plan (see Table) were implemented and updated every 24 hours. When a pressure ulcer was discovered, an event report was generated. The event reports were used to track the occurrence of pressure ulcers and the nursing actions used to start treatment. Several factors were contributing to a high prevalence of HAPUs, including lack of comprehensive skin assessment upon admission, absence of an event report and image note for patients who had pressure ulcers at the time of admission, inconsistent and inaccurate measurements of pressure ulcers, incomplete Braden Scale scoring, and inconsistencies in the treatment plan. Staff Education The wound liaison nurse compiled a 3-part, self-learning, 30-page educational manual on skin care. Posters of skin care products were created in collaboration with the wound team and were posted in highly visible areas throughout the PCU. All new staff nurses are educated on the identification, documentation and treatment of skin breakdown. Nursing Assistants A major change in practice was including the nurse assistants in the treatment and management of pressure ulcers. This new practice led to improved continuity of care and enhanced teamwork. Early detection and prevention are important elements in treating pressure ulcers. Including the nurse assistants in the Healthy Skin Project allowed for early detection and was the final step in creating a multidisciplinary team approach. CCN Skin tears Cleanse with physiological saline Close approximate edges Cover with nonadherent dressing and gauze roll Change dressings daily and as needed Elevate heels off bed Turn patient every 2 hours Table Skin care plan Pressure ulcers Stage I Stage II Stage III or IV Lesion with intact Notify physician blister: Position patient off affected area Lesion shallow and moist: Cover with 1 layer of nonadherent gauze dressing, secure, change daily Lesion shallow and dry: Cover with 3 layers of nonadherent gauze dressing, secure, change daily Wet lesion: Cover with multiple layers of gauze, secure, and change daily Dry lesion: Cover with multiple layers of nonadherent gauze, secure, and change daily Unstageable necrotic tissue Notify physician Dry eschar Cover with multiple layers of nonadherent gauze, secure, and change daily Deep tissue injury Notify physician Elevate heels off bed Armour-Burton T, Fields W, Outlaw L, Deleon E. The Healthy Skin Project: Changing Nursing Practice to Prevent and Treat Hospital-Acquired Pressure Ulcers. Critical Care Nurse. 2013;33(3):32-40.

10 The Healthy Skin Project: Changing Nursing Practice to Prevent and Treat Hospital-Acquired Pressure Ulcers Teri Armour-Burton, Willa Fields, Lanie Outlaw and Elvira Deleon Crit Care Nurse 2013; /ccn American Association of Critical-Care Nurses Published online Personal use only. For copyright permission information: Subscription Information Information for authors Submit a manuscript alerts Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA Telephone: (800) , (949) , ext Fax: (949) Copyright 2016 by AACN. All rights reserved.