Rehabilitation Nursing • Vol. 30, No. 3 • May/Jun 2005 85
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. Pres-
sure sores affect 1 million persons in acute care and
nursing home settings. Seeley, Jensen, and Hutcher-
son (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 bil-
lion. 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 ad-
dition, 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 (Ol-
son 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 break-
down, 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,
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 Cat-
egory 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 par-
tial 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 wheel-
chair 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 preven-
tion, assessment, and treatment of pressure sores
and/or skin tears for clients on a residential Alzheim-
er’s disease unit.
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.
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 educa-
tion, 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.
skin care program
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Rehabilitation Nursing • Vol. 30, No. 3 • May/Jun 2005 91
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Rodeheaver, G. T. (1999). Pressure sore debridement and
cleansing: A review of current literature. Ostomy/Wound
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Stotts, N. A., & Cavanaugh, C. E. (1999). Assessing the patient
with a wound. Home Healthcare Nurse, 17, 27–35.
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Parnell, L. K. S. (1999). A comparison of an opaque foam
dressing versus a transparent film dressing in the manage-
ment of skin tears in institutional subjects. Ostomy/Wound
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van Rijswijk, L. (1999). Clinical practice guidelines: Moving into
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