Skin Integrity, Pressure-Injury Prevention, Splints & Compression Devices

Pressure Injury Staging

A pressure injury, formerly called a pressure ulcer or bedsore, develops when sustained pressure, often over a bony prominence such as the sacrum, heels, hips, or elbows, cuts off blood flow to the skin and underlying tissue. The National Pressure Injury Advisory Panel (NPIAP) staging system is tested heavily on the CPCT/A exam:

The PCT's role is prevention and early detection, not staging or treating a wound. Any suspicious redness, discoloration, or skin breakdown must be reported to the nurse immediately rather than monitored independently.

Repositioning and Pressure Redistribution

The standard prevention interval taught for immobile patients is to reposition at least every 2 hours (q2h), redistributing pressure off bony prominences. Patients who can shift their own weight while seated should do so every 15 to 30 minutes, with a full assisted position change at least every hour in a chair or wheelchair. Supporting measures include:

• Air or alternating-pressure mattresses, which cycle inflation across internal cells to continuously redistribute pressure under the patient.
• Draw sheets, a folded sheet placed under the patient and used to reposition or boost the patient in bed by lifting and pulling rather than dragging, which protects the skin from friction and shear injury.
• Keeping the head of the bed as low as the patient's condition safely allows, since a raised head of bed increases shear forces as the patient slides downward, and keeping skin clean, dry, and moisturized.

Signs of Impaired Circulation

The PCT must recognize and immediately report signs that circulation to a limb or pressure area is compromised: pale, white, blue or cyanotic, or dusky skin color; skin that feels cool to the touch; numbness or tingling; a diminished or absent pulse distal to the area; delayed capillary refill greater than about 3 seconds; and new swelling. These signs are especially important to check after applying any splint, cast, restraint, or compression device, since a device that is fitted too tightly can cut off blood flow to the limb.

Immobility Splints

Splints immobilize a joint or limb to prevent movement, whether for comfort, to protect a healing injury, or to prevent contractures in a patient who cannot move independently. When assisting with or checking a splint, the PCT should confirm it is snug but not tight, generally able to fit one finger underneath, check the skin under and around the splint for redness or breakdown, and check circulation, sensation, and movement of the fingers or toes distal to the splint on a regular schedule, reporting any change immediately.

Sequential Compression Devices and Antiembolism Stockings

Both devices prevent deep vein thrombosis (DVT) in immobile patients by promoting venous blood return from the legs to the heart, but they work through different mechanisms:

• Sequential compression devices (SCDs) are inflatable plastic sleeves connected by tubing to a pump. The sleeves inflate in sequence from ankle to calf or thigh and then deflate, mechanically milking blood upward toward the heart.
• Antiembolism (TED) stockings are tight elastic hose that apply continuous graduated pressure, tightest at the ankle and gradually decreasing up the leg.

Both are contraindicated in a patient with a known or suspected existing DVT, since compressing an existing clot risks dislodging it and causing a pulmonary embolism, as well as in patients with significant leg wounds, severe peripheral vascular disease, or dermatitis in the area. The PCT should check the care plan and report any leg swelling, redness, or pain before applying either device, and should remove stockings or SCD sleeves briefly during routine care to inspect the skin underneath and confirm proper fit.

Additional Risk Factors and Daily Skin Checks

Beyond immobility, several other factors raise a patient's pressure-injury risk and should heighten the PCT's vigilance: poor nutrition and hydration, incontinence that keeps skin moist and exposed to irritants, decreased sensation that prevents a patient from feeling early discomfort, and friction or shear forces created when a patient is dragged rather than lifted during repositioning. Friction scrapes the outer layer of skin, while shear occurs when deeper tissue layers move in one direction while the skin surface stays fixed, such as when a patient slides down in a raised bed; both mechanisms damage tissue even without direct pressure. A brief skin check during routine care, such as bathing or repositioning, is one of the most effective prevention tools available to the PCT, since catching a Stage 1 injury early and relieving pressure from that area can prevent progression to a deeper, harder-to-heal wound. Any new area of redness, warmth, or skin breakdown found during a routine check should be reported the same shift it is discovered, not held until the next scheduled skin assessment.