Page 43 - UNC MC Assistive Personnel Orientation Manual 2020

Skin Care / Wound Ostomy Continence Nurse Consult Service

Risk Factors Related to Pressure Injuries

Sensory Perception
• The ability to respond to pressure related discomfort.
•Elderly, diabetic, sedated, etc. often won't feel pressure and may not
respond by moving. This may possibly result in a pressure injury.

Moisture
•Sources of moisture could macerate skin and make it more prone to
breakdown and/or fissures.
• perspiration ● urine
• stool ● wound drainage

Activity
• Decreased physical activity such as being confined to bed/chair for
extended periods of time) increases chance for skin breakdown.
• Less activity also decreases the appetitie which increase the chance for
skin breakdown.

Mobility

•Decreased mobility will increase the time the patient spends in the
same position.
•This increases pressure placed on the bony prominences where skin
breakdown will most likely occur.

Friction and Shear
•As the patient slides down in the bed both friction and shear injury
occur.
•Friction during moving and transferring can cause damage to the skin.

Nutrition

•Inadequate nutrition increases probability of skin breakdown.
•Nurtitional deficits can be addressed by mouth (supplements, tube feedings or
TPN.
•Protein is the most important dietary factor for wound healing!

Intake and Output
•Accurate recording of intake and output helps to direct patient care.

Nursing Practice and Professional Development / Assistive Personnel Orientation 2020 Page 40