S5 · Likely to develop pressure sores
Risk Safety and protection
Definition
Staying in one position, moisture, or poor nutrition raise the chance of skin breakdown over bony areas.- Immobility
- moisture
- poor nutrition
- older age
- diabetes
- thin skin
- Red skin that does not fade
- warm or hard spots over bony areas
- pain at pressure points
📋 Scenario
A thin, bedbound older patient with a poor appetite stays in the same position for long periods.
Subjective (S): "I cannot move myself much."
Objective (O): Thin and bedbound; skin over the sacrum intact and turns white when pressed; moist skin; poor appetite; high pressure-injury risk score.
Assessment tools for this scenario: CP-SAFE Safety & Falls Score CP-SKIN Skin & Wound Score
Validated scales to consider: Morse Fall Scale, Braden Scale, TIME wound chart
**CarePath diagnosis:** Likely to develop pressure sores related to immobility, moisture and poor nutrition (risk factors); no signs of the problem are present yet.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Turn every 2 hours or per plan. | Regular turning relieves pressure over bony areas, which restores blood flow to the skin and prevents tissue damage. |
| Check skin. | Checking the skin finds early damage, such as redness that does not fade, while it can still be reversed. |
| Use a pressure-relieving mattress. | A pressure-relieving mattress spreads body weight over a wider area, so less pressure falls on the sacrum and other bony points. |
| Keep skin clean and dry. | Moisture softens skin and makes it easier to damage, so keeping it clean and dry protects it. |
| Encourage nutrition. | Protein, calories and fluids are needed to maintain healthy skin and repair damage, so good nutrition lowers risk. |
| Lift, do not drag. | Dragging causes friction and shear that damage skin, while lifting avoids rubbing across the sheet. |
**Expected outcomes**
- Skin stays intact.
- Redness resolves within 3 days.
- Position changed at least every 2 hours.
- Food intake improves toward goal.
**Linking the data to the diagnosis**
The thin, bedbound older patient says they cannot move much, has moist skin, a poor appetite and a high pressure-injury risk score. The skin over the sacrum is intact and turns white when pressed, so no damage has occurred. Because the skin is not broken or damaged, this is a risk diagnosis and not an actual skin problem such as broken or damaged skin. The risk factors are immobility, moisture and poor nutrition. The plan aims for skin to stay intact, position changes at least every 2 hours, and food intake improving toward the goal.
CarePath diagnosis
Likely to develop pressure sores related to immobility, moisture and poor nutrition (risk factors); no signs of the problem are present yet.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Turn every 2 hours or per plan. | Regular turning relieves pressure over bony areas, which restores blood flow to the skin and prevents tissue damage. |
| 2. Check skin. | Checking the skin finds early damage, such as redness that does not fade, while it can still be reversed. |
| 3. Use a pressure-relieving mattress. | A pressure-relieving mattress spreads body weight over a wider area, so less pressure falls on the sacrum and other bony points. |
| 4. Keep skin clean and dry. | Moisture softens skin and makes it easier to damage, so keeping it clean and dry protects it. |
| 5. Encourage nutrition. | Protein, calories and fluids are needed to maintain healthy skin and repair damage, so good nutrition lowers risk. |
| 6. Lift, do not drag. | Dragging causes friction and shear that damage skin, while lifting avoids rubbing across the sheet. |
Expected outcomes
- Skin stays intact.
- Redness resolves within 3 days.
- Position changed at least every 2 hours.
- Food intake improves toward goal.
Linking the data to the diagnosis
The thin, bedbound older patient says they cannot move much, has moist skin, a poor appetite and a high pressure-injury risk score. The skin over the sacrum is intact and turns white when pressed, so no damage has occurred. Because the skin is not broken or damaged, this is a risk diagnosis and not an actual skin problem such as broken or damaged skin. The risk factors are immobility, moisture and poor nutrition. The plan aims for skin to stay intact, position changes at least every 2 hours, and food intake improving toward the goal.