Using a prognostic medical device for early identification of pressure ulcers: protocol for study design.

BACKGROUND: An objective, physiological measurement taken using a medical device may reduce the incidence of pressure ulcers through earlier detection of problems signs before visual signs appear. Research in this field is hampered by variations in clinical practice and patient-level confounders. AIM: The authors outline key considerations for designing a protocol for a study to assess the efficacy and safety of a prognostic medical device in reducing pressure ulcer incidence in a hospital, including comparators, randomisation, sample size, ethics and practical issues. METHOD: Key issues relating to methodology and ethics are considered alongside a theoretical protocol, which could support future researchers in wound care trials. RESULTS: A prospective, three-armed, multi-centre, stratified cluster-randomised controlled trial is proposed. The third arm is recommended as it is expected that patients will need to be moved for the medical device to be used and repositioning is a preventive strategy. A minimum of 16 200 patients in 33 wards would needed to be recruited to achieve statistical significance. Ethical considerations in terms of consent or assent need to be considered. CONCLUSION: The hypothetical study designed to evaluate the effectiveness of a diagnostic or prognostic medical device in reducing pressure ulcer incidence in secondary care, while accounting for biases, would require large sample sizes and involves risks of inter-operator and inter-device reliability, heterogeneity of users and the vague clinical interpretation of device results. Robust research in this field has the potential to influence or change policy and practice relating to the prevention of pressure ulcers in secondary care.

Wound care in older people: overcoming the challenges of assessment and management.

Age-related skin changes lead to increased susceptibility to skin damage and delayed wound healing, which is exacerbated by comorbidities such as cardiovascular disease and diabetes mellitus. In some cases, wound healing is not achievable or realistic and this needs to be reflected in the wound management plan. To improve outcomes and experience in older people presenting with wounds it is important to select wound management products that protect the wound bed and surrounding skin, minimise trauma, reduce symptoms and/or promote healing. This article explores how conducting holistic wound assessments, setting realistic treatment aims, and using wound management strategies tailored to each person's needs and wishes can have a positive effect on older people's quality of life.

Diagnosing, assessing and managing cellulitis.

Cellulitis is an acute bacterial infection that affects the deep dermis and surrounding subcutaneous tissue. Although it is a common condition, it is often misdiagnosed because it can mimic a range of conditions that also cause inflamed, red, irritated and painful skin. Such misdiagnoses may lead to unnecessary hospital admissions and antibiotic overuse, with most alternative diagnoses being non-infectious. Undertaking a holistic patient assessment, skin assessment and thorough clinical history is important in the diagnosis of cellulitis, and it is vital to use a collaborative multidisciplinary approach in its acute management and to prevent recurrence. This article defines the term cellulitis and explores its presenting features. The author also discusses the associated risk factors, clinical assessment techniques and effective management strategies, as well as outlining the actions that nurses can take to prevent recurrence.

Machine learning (ML) techniques as effective methods for evaluating hair and skin assessments: A systematic review.

Machine Learning (ML) techniques provide the ability to effectively evaluate and analyze human skin and hair assessments. The aim of this study is to systematically review the effectiveness of applying Machine Learning (ML) methods and Artificial Intelligence (AI) techniques in order to evaluate hair and skin assessments. PubMed, Web of Science, IEEE Xplore, and Science Direct were searched in order to retrieve research publications between 1 January 2010 and 31 March 2020 using appropriate keywords such as "hair and skin analysis." Following accurate screening, 20 peer-reviewed publications were selected for inclusion in this systematic review. The analysis demonstrated that prevalent Machine Learning (ML) methods comprised of Support Vector Machine (SVM), k-nearest Neighbor, and Artificial Neural Networks (ANN). ANN's were observed to yield the highest accuracy of 95% followed by SVM generating 90%. These techniques were most commonly applied for drafting framework assessments such as that of Melanoma. Values of parameters such as Sensitivity, Specificity, and Area under the Curve (AUC) were extracted from the studies and with the help of comparisons, relevant inferences were also made. ANN's were observed to yield the highest sensitivity of 82.30% as well as a 96.90% specificity. Hence, with this systematic review, a summarization of the studies was drafted that encapsulated how Machine Learning (ML) techniques have been employed for the analysis and evaluation of hair and skin assessments.

Preventing, assessing and treating skin tears.

Skin tears are acute wounds caused by mechanical forces resulting in the separation of the skin's outer layers. Skin tears are more likely to occur in vulnerable people such as older people and people with neurodegenerative conditions. Rising life expectancy means that the number of patients with skin tears is expected to increase. This article describes the characteristics of skin tears, details the risk factors for skin tears and explains the importance of using a holistic, evidence-based and person-centred approach to skin tear prevention, assessment and treatment. The article outlines the crucial role of nurses as part of the multidisciplinary team in the management of skin tears.

Perioperative Risk Assessment for Skin Injury.

Hospital-acquired pressure injuries create a tremendous cost to health care organizations and negatively affect quality and patient safety. Surgical patients are at an increased risk for skin injury, particularly a pressure injury, because of a lack of sensation and immobility during a procedure. An interprofessional team at our facility identified factors that place surgical patients at risk for skin injury. We developed a risk assessment protocol in March 2021 using the Six Sigma DMAIC (define, measure, analyze, improve, and control) method. After data review and analysis, we identified age of 65 years or older, existence of a skin condition, and procedural duration greater than four hours as significant predictors for postoperative skin injury. Our findings reinforce the benefit of using an appropriate risk assessment protocol that alerts the perioperative team members to at-risk patients.

Hyperspectral assessment of acne skin exposed to intense pulsed light (IPL) intense pulsed light in acne treatment.

BACKGROUND: The mechanism of intense pulsed light action on the skin is based on selective photothermolysis. The light delivered to the tissue is scattered and absorbed by chromophores that absorb a beam of radiation of a specific length. The skin reflectance changes depending on the physiological state of the tissue, as shown by the hyperspectral camera. The aim of the study was to assess the hyperspectral reflectance of acne skin before and after intense pulsed light (IPL) therapy and to compare it with the reflectance of healthy skin. MATERIALS AND METHODS: The study involved 27 volunteers with diagnosed moderate acne. The control group consisted of 20 people without acne lesions. All acne volunteers underwent a series of four treatments using IPL at weekly intervals. The volunteers with acne lesions were photographed before the series of treatments and a week after the 4th treatment. RESULTS: Acne skin shows lower reflectance than healthy skin. Acne skin after IPL therapy is characterized by a higher reflectance compared to acne skin before the therapy and resembles the reflectance of the skin of the control group. A statistically significant difference was found between the acne skin before the treatments and the skin of the control group. CONCLUSIONS: The effect of IPL therapy on acne skin is the increase of its reflectance by reducing the number of chromophores, which brings it closer to the reflectance value of healthy skin. Hyperspectral imaging allows for: the evaluation of the treated skin at each stage, a precise selection of the light wavelength depending on the problem, and therefore, for optimizing the number of irradiations and increasing the safety of the therapy.

Spatial and temporal changes in biophysical skin parameters over a category I pressure ulcer.

In acute care facilities, the detection of pressure ulcers (PUs) relies on visual and manual examination of the patient's skin, which has been reported to be inconsistent and may lead to misdiagnosis. In skin and wound research, various biophysical parameters have been extensively employed to monitor changes in skin health. Nonetheless, the transition of these measures into care settings as part of a routine clinical assessment has been limited. This study was designed to examine the spatial and temporal changes in skin biophysical parameters over the site of a category I PU, in a cohort of hospitalised patients. Thirty patients, each presenting with a category I PU, were enrolled in the study. Skin integrity was assessed at the PU-compromised site and two adjacent areas (5 and 10 cm away). Data was collected over three sessions to examine both temporal differences and longitudinal changes. Skin integrity was assessed using two biophysical parameters, namely, transepidermal water loss (TEWL) and stratum corneum (SC) hydration. In addition, the influence of intrinsic factors, namely, incontinence and mobility status, on the parameters was evaluated. TEWL values at the sites compromised by PU were statistically significantly greater (P < .001) than corresponding values at the adjacent control sites at 5 and 10 cm, which were consistent with a normative range (<20 g/h/m2 ). By contrast, SC hydration values did not reveal clear distinctions between the three sites, with high inter-patient variation detected at the sites. Nevertheless, individual profiles were consistent across the three sessions, and the PU site was observed to be either abnormally dry or overhydrated in different individuals. No consistent temporal trend in either parameter was evident. However, intrinsic factors were shown to influence the parameters, with females, bedridden and incontinent patients presenting significantly higher TEWL and SC hydration values (P < .05). TEWL was able to identify differences in skin responses at skin sites compromised with a category I PU when compared to healthy adjacent skin sites. Accordingly, this parameter could be included in the clinical assessment for the identification of PU risk. Further studies are required to elucidate the role of hydration and skin barrier function in the development of PUs and their ability to monitor temporal changes in skin integrity.

Use of point-of-care subepidermal moisture devices to detect localised oedema and evaluate pressure injury risk: A scoping review.

AIMS AND OBJECTIVES: To map current literature on bedside clinicians' use of point-of-care subepidermal moisture devices to identify increased pressure injury risk. BACKGROUND: Pressure injuries are a substantial healthcare burden. Localised oedema occurs before visible or palpable changes, and therefore is a biomarker of increased pressure injury risk. Novel bedside technologies that detect localised oedema may aid early pressure injury preventative practices. DESIGN: A scoping review. METHODS: Arksey and O'Malley's six-step framework and the PRISMA-ScR guidelines guided this scoping review. CINAHL Complete, Embase, SCOPUS, Cochrane (wounds) and PubMed databases were searched for primary research and quality improvement projects published in English between 2008-2022. Included studies focused on clinicians' bedside use of subepidermal moisture devices to quantify localised oedema and pressure injury risk. The PAGER framework supported narrative synthesis of the extracted data. RESULTS: Nine studies were selected from 1676 sources. Two point-of-care subepidermal moisture devices were identified in clinical use, largely by nurses. Inconsistent use and interpretations revealed significant knowledge gaps in clinical practice. Additionally, no included studies engaged patients or the public in their design. CONCLUSIONS: Nurses recognise the value of objective measures in determining the risk of pressure injury and are the primary end-users of point-of-care subepidermal moisture devices. However, standardising procedural instructions and interpretive criteria to guide preventative measures requires further research. RELEVANCE TO CLINICAL PRACTICE: International pressure injury clinical practice guidelines advocate for subepidermal moisture devices as an adjunct to routine clinical skin assessment, although little is known about bedside use. This scoping review reveals low adoption of such devices and the need to develop standardised procedures in their use and interpretation. REGISTRATION: Open Science DOI https://doi.org/10.17605/OSF.IO/AB6Y5-7th of March 2022.

The effect of sub-epidermal moisture on pressure injury prevention strategies and incidence of pressure injuries: A feasibility pilot randomised controlled trial.

AIM: Sub-epidermal moisture scanning (SEMS) is a novel point-of-care technology that measures localised oedema and detects early tissue damage that may develop into a pressure injury (PI). It provides objective data that may assist PI prevention (PIP) decision making. This study aimed to determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to test the effectiveness of SEMS. MATERIALS AND METHODS: This pilot RCT recruited medical and surgical patients at risk of developing a PI in one Australian hospital. All participants received routine PIP care and daily visual skin assessment to determine the presence of a PI. The intervention group also received daily SEMS. Clinical staff were told if the sub-epidermal moisture (SEM) value was abnormal but were not given advice for PIP. Blinding of patients, care staff and outcome assessors was not practical. Feasibility outcomes included recruitment, retention, intervention fidelity, and patient outcomes. RESULTS: Of 1185 patients screened prior to eligibility, 950 were excluded (80%); 235 were then assessed for eligibility and 160 met the inclusion criteria (68.1%); 100 were recruited (70.0%) and randomised and 99 completed the trial (intervention n = 50; control n = 49) with one person withdrawn due to inappropriate recruitment (100% retention). Of the 657 expected SEMS observations, 598 were completed (91% intervention fidelity). Only 34 of 454 (7.4%) patient outcome data points were missing. CONCLUSIONS: Most feasibility criteria were met, indicating a definitive trial to assess the effectiveness of SEMS in a medical-surgical patient population is realistic. However, recruitment may be resource intensive and require specific strategies.

Measuring subepidermal moisture to detect early pressure ulcer development: a systematic review.

OBJECTIVE: The aim was to assess evidence related to the measuring of subepidermal moisture (SEM) to detect early, nonvisible development of pressure ulcers (PUs). METHOD: Using systematic review methodology, all quantitative animal and human research studies written in English were considered. In January 2021, PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases were searched. The primary outcome of interest was the validity of SEM measurement to detect early PU development. The secondary outcome was time to PU detection, sensitivity and specificity of SEM measurement, and the impact of SEM measurements on PU prevention. Data analysis was undertaken using RevMan and narrative synthesis. RESULTS: A total of 17 articles met the inclusion criteria. In all studies, a consistent abnormal deviation in SEM measurements corresponded with evidence of visual PU development. Time to PU development, explored in four studies, showed earlier detection of PU development using SEM measurement. RevMan analysis identified the mean difference in time to PU development (SEM measurement versus visual skin assessment, VSA) was 4.61 days (95% confidence interval: 3.94-5.28; p=0.0001) in favour of SEM measurements. The sensitivity of SEM measurements was reported in four studies, and scores varied from 48.3% to 100.0%. Specificity was also reported in four studies and scores ranged from 24.4% to 83.0%. The impact of the detection of abnormal SEM measurements on PU prevention was explored by one study. Results showed a 93% decrease in PU rates when staff acted on the results of the SEM readings. CONCLUSION: The findings of this review identified that SEM measurement detects PU development earlier than VSA. Furthermore, when staff responded to abnormal SEM measurements, prevention strategies were enhanced, with a subsequent reduction in visible PU development. SEM measurement may therefore be a useful addition to PU prevention strategies. DECLARATION OF INTEREST: The School of Nursing & Midwifery, RCSI has a research agreement with Bruin Biometrics. Funding for the study was through an Irish Research Council PhD Enterprise Partnership Scheme with Bruin Biometrics. The authors have no other conflicts of interest.

Prevention of pressure ulcers in older people with frailty.

The incidence of pressure ulcers is highest among older people with frailty. The development of pressure ulcers is a common and challenging issue in this population, which can reduce people's quality of life and increase mortality risk. Multifactorial processes contribute to the development of pressure ulcers in older people with frailty, including age-related skin changes, comorbidities, polypharmacy, reduced mobility, inadequate nutrition and hydration, and continence issues. This article discusses the development and management of pressure ulcers in older people with frailty. It also outlines some of the measures that can be taken by nurses and other healthcare professionals to reduce the risk of pressure ulcers developing in this population.

Sub-epidermal moisture assessment as a prompt for clinical action in treatment of pressure ulcers in at-risk hospital patients.

OBJECTIVE: This study assesses anonymous patient-level data on the use of sub-epidermal moisture (SEM) assessment technology as a tool in the prevention of pressure ulceration in at-risk hospital patients. METHOD: The relationship between technology-generated prompts for clinical action (patient turning, application of pressure redistributing equipment, heel protection or cream) and consequent clinical action was evaluated using data cross-tabulations (using data aggregated over multiple anatomical sites); in a multilevel model with patients clustered within wards, clustered in turn within hospitals, and controlling for additional patient- and institution-level factors; and using receiver operating characteristic (ROC) analyses of anatomy-specific data. The ability of the SEM assessment technology to detect deep and early-stage pressure ulcers/injuries on specific anatomical areas of a patient's body on admission, earlier than visual and tactile skin tissue assessments (STA), was assessed. RESULTS: A total of 15,574 patient assessments ('cases') were reported on 1995 patients. Most incidences of nurse action were in response to a prompt from SEM assessments (4944/5494; 90.0%). An SEM delta (Δ)≥0.6 resulted in nurse action in 4944/13,071 cases (37.8%). The multilevel model revealed strong evidence that SEM Δ prompts were significantly associated with nurse action (p<0.001; adjusted odds ratio: 1.99). CONCLUSION: In this study, SEM assessment technology effectively prompted nurse action moreso than skin reddening diagnosed via trained clinician judgement and STAs. While baseline responses of nurses' actions remained low, with or without SEM Δ prompts, findings verified the 'clinical utility' of SEM assessment technology as an objective prompt for early clinical action over and above existing mechanisms.

Sub-epidermal moisture versus traditional and visual skin assessments to assess pressure ulcer risk in surgery patients.

OBJECTIVE: To compare the predictive ability of subepidermal moisture (SEM) measurement versus traditional risk assessment and visual skin assessment (VSA) as means of detecting early pressure ulcer (PU) damage development among adults undergoing surgery. METHOD: A non-experimental, comparative, descriptive cohort study design was used. Following ethical approval, participants who had given their informed written consent had their skin assessed over the areas that were weight-bearing during surgery, using VSA and the SEM measurement. Visual PUs were graded according to the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel ulcer grading system. Assessments took place preoperatively, then daily on the ward, beginning on day one postoperatively and continuing for three days or until discharge. RESULTS: Of the 231 participants, who had a mean age of 57.50 years, 55.8% (n=129) were male. The most common comorbidity was cardiology/vascular (n=42; 18.2%). Just over half (52.4%; n=121) underwent orthopaedic surgery and 47.6% (n=110) underwent non-orthopaedic surgery; 70% (n=163) received a general anaesthetic and 43% (n=100) were in the supine decubitus position during surgery. PU incidence was 51% (n=116), according to SEM measurement, and 3% (n=7) according to VSA. Among the seven participants who developed a visual PU, 10 PUs at stage 1 developed (31%); some patients developed more than one PU. Of the participants who had assessments for three days postoperatively, 94% (n=61) had a persistently high SEM delta on day three. The variables that emerged as statistically significantly related to abnormal SEM measurement deltas among these participants were: surgery duration (p=0.038); having orthopaedic surgery (p=0.020); supine surgical position (p=0.003); spinal anaesthetic type (p=0.0001); and Waterlow and Braden mobility subscale day one postoperatively (p=0.0001). None of the variables had a statistically significant influence on abnormal VSA. CONCLUSION: Surgical patients, because of immobility, are vulnerable to the action of compression and shear forces. These forces cause changes at a cellular level that trigger inflammation, which is a precursor to early tissue damage. SEM measurement can detect this tissue damage from the increase in the underlying tissue water content that results from inflammation. From the findings of this study, SEM measurement is very promising in the detection of early tissue damage in those at risk of PU development among the surgical population.

Preventing pressure ulcers in emergency departments: four simple and effective nurse-led changes.

Patients can develop pressure ulcers within a few hours of entering an emergency department (ED). However, despite the critical role of EDs in reducing the incidence of pressure ulcers, few have protocols in place for prevention. This article describes the prevention emergency project (PEP), a quality improvement project undertaken in the ED at Karolinska University Hospital in Sweden to reduce the incidence of pressure ulcers. The article demonstrates how four simple nurse-led changes - early risk assessment, pressure-relieving equipment, intentional rounding, and using prophylactic dressings and incontinence pads - can reduce the incidence of pressure ulcers significantly when integrated into ED workflow.

Improving Skin Assessment Documentation in the Electronic Health Record to Prevent Perioperative Pressure Injuries.

Perioperative leaders at a pediatric trauma hospital initiated an examination of the existing processes for pressure injury prevention. They assembled a workgroup comprising a wound and skin clinical nurse specialist, a nursing informatics specialist, and a perioperative nurse specialist who applied a proven change management framework to guide their efforts. The workgroup identified a critical gap in the documentation features in the electronic health record: nurses were unable to communicate skin assessment and pressure injury information easily and consistently across services (eg, inpatient, emergency department, surgical services). Using evidence from nursing and pressure injury associations on skin assessments, interventions, and documentation, the workgroup developed, trialed, and implemented updated documentation fields, making them consistent throughout the electronic health record. Based on postimplementation survey responses, nurses at the hospital are highly satisfied with the changes. The surgically acquired pressure injury rate at the hospital continues to remain low.

The Clinical Nursing and Midwifery Dashboard (CNMD): A State-Wide Implementation.

The clinical nursing and midwifery dashboard (CNMD) was built to provide a near real-time information and data visualisations for nurse unit managers (NUMs) and maternity unit managers (MUMs) within only a 5-15 minutes delay from when they enter data to the integrated electronic medical records (ieMR) system. The dashboard displays metrics and information about current adult inpatients in overnight wards. The aim is to support NUMs and MUMs to manage their daily workload and have continuous visibility of patients nursing risk and safety assessment documentation. A quantitative evaluation approach was conducted to measure the impact of the dashboard on key performance indicators. Statistical analysis was completed to compare risk assessment average completion times prior to and post CNMD implementation. The results of the evaluation were positive, and the statistical analysis shows significant reduction in the average time to complete different risk assessments with p-value<0.01.

Evaluating the impact on hospital acquired pressure injury/ulcer incidence in a United Kingdom NHS Acute Trust from use of sub-epidermal scanning technology.

BACKGROUND: The incidence of pressure injury/ulcers is persistent despite multiple prevention strategies in hospitals across the globe. Current standard of pressure injury/ulcer care supported by subjective skin tissue assessments, risk assessment tools and clinical judgement is ineffective in consistent pressure injury/ulcer prevention. AIM: A pragmatic study, aligning with SQUIRE guidelines, was conducted at Chelsea and Westminster hospitals to measure the impact of adding scanning technology to the prevailing standard of care pathway on the incidence of category 2-4 hospital-acquired pressure injury/ulcers. METHODS: Six hundred and ninety-seven mixed-population patients at risk for pressure injuries/ulcers with a Waterlow score of ≥10 and a mean age ≥65 years were enrolled across four wards over a 6-month period. Scanning technology was added to the prevailing standard of care as a device adjunctive to clinical judgement for the detection of deep and early-stage pressure-induced tissue damage. Ward staff completed comprehensive device training by the device manufacturer. Clinical interventions were initiated by clinical judgement informed by injury/ulcer risk assessments, skin and tissue assessments and scanner readings. Incidence of reportable category 2-4 pressure injuries/ulcers from the prior 12-month period from the same wards were used as a control comparator population. All diagnosed category 2-4 pressure injuries/ulcers, unstageable and deep-tissue injuries were recorded. RESULTS: Prior study 12-month pressure injury/ulcer incidence was 0.6% (5/892 patients) in ward A, 4.4% (9/206 patients) in Ward B, 1.1% (12/1,123 patients) in Ward C and 2.6% (16/625 patients) in Ward D. Two pressure injury/ulcers in Ward B were recorded during the study. Zero pressure injuries/ulcers were recorded in the remaining three wards resulting in an 81% incidence reduction across all four wards. Improved clinical decisions from clinical judgement based on Sub-Epidermal Moisture (SEM) Scanner data were reported in 83% patients (n=578/697). CONCLUSION: Implementing scanning technology into routine clinical practice achieves consistent reductions in pressure injury/ulcer incidence.

Clinical impact of a sub-epidermal moisture scanner: what is the real-world use?

OBJECTIVE: The presence of sub-epidermal moisture (SEM) over a bony prominence is indicative of incipient pressure ulcer (pressure injury/decubitus/bedsore) (PU). Early identification of patients at increased risk of PU can prompt interventions that reduce the incidence and severity of hospital (or community)-acquired PUs (HAPUs). This study evaluated the clinical utility of a SEM Scanner device in HAPU management. METHOD: The study used a pragmatic 'real-world' approach. HAPU data before and during SEM Scanner use were obtained through routine audit. Patients had regular visual and daily SEM Scanner skin assessments over the sacrum and heels. Nursing care otherwise followed standard of care according to the established protocols of individual participating sites. HAPU incidence rates were determined and feedback gathered from health professionals on how the device influenced HAPU-related clinical decision-making. RESULTS: There were 15 participating sites: 13 acute care, one palliative care and one community care setting. The sample size was 1478 patients. All sites reported a substantial reduction in mean HAPU incidence: 87.2% in acute care settings; 46.7% in the palliative care setting and 26.7% in the community care setting. A 100% incidence reduction was reported in 10 (66.7%) sites. In the palliative care setting, SEM Scanner results changed HAPU-related clinical decision-making for 40% of patients scanned. The community care site demonstrated a 82% change in clinical decision-making. CONCLUSION: In this study, SEM analysis fitted seamlessly into routine skin assessment and enabled early identification of increased risk of tissue damage, with clinically important reductions in the incidence of HAPU across all participating sites.

Using the 'aSSKINg' model in pressure ulcer prevention and care planning.

Pressure ulcers are painful, costly and can negatively affect a patient's quality of life. It has long been recognised that they increase the risk of infection, prolong hospital stays and can result in death. To prevent the occurrence of pressure ulcers, nurses need to understand what a pressure ulcer is and the underlying factors that cause them. Furthermore, it is essential that they recognise why some people are more susceptible to pressure and shear forces than others, so that preventable factors can be addressed. Nursing care to prevent pressure ulcers needs to be planned, implemented and evaluated in a systematic manner following an assessment of the patient and their circumstances. The 'aSSKINg' (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) model ensures all fundamental aspects of pressure ulcer prevention are included in patient care. This article outlines the definitions and causes of pressure ulcers, and explains how nurses can assess, plan, implement and evaluate pressure ulcer preventative care using the aSSKINg model as a guide.