Risk for neonatal pressure injury

NANDA Nursing Diagnose - Risk for neonatal pressure injury

Código del diagnóstico: 00288
Dominio del diagnóstico: Domain 11 - Safety - protection
Clase del diagnóstico: Class 2 - Physical injury

Understanding the NANDA-I diagnosis 'Risk for neonatal pressure injury' is crucial in nursing practice, particularly for those caring for vulnerable neonatal populations. This diagnosis underscores the necessity of comprehensive assessments and proactive interventions to prevent localized skin damage in neonates, whose fragile skin and underlying tissues make them particularly susceptible to pressure injuries. As healthcare professionals, acknowledging and addressing this risk not only enhances patient care but also supports optimal recovery in neonates, fostering better long-term health outcomes.

This post delves into the NANDA-I diagnosis 'Risk for neonatal pressure injury', beginning with a clear definition to establish a strong foundation. An in-depth exploration will follow, examining various contributing factors, risk populations, and associated conditions, ensuring a comprehensive understanding of this significant diagnosis. By examining these aspects, the post aims to equip healthcare professionals with the knowledge needed to recognize and manage this risk effectively, enhancing care for our youngest patients.

Definition of the NANDA-I Diagnosis

The diagnosis of 'Risk for neonatal pressure injury' refers to the heightened vulnerability of neonates, particularly those up to 29 days old, to localized damage to their skin and underlying tissues due to the prolonged application of pressure, or a combination of pressure and shear forces, which can lead to significant health complications if not addressed. This risk is particularly pronounced in populations such as low birth weight infants or those born prematurely, specifically those under 32 weeks gestation, and is exacerbated in environments like neonatal intensive care units where external factors—such as inadequate access to appropriate medical supplies, equipment, and caregiver knowledge regarding pressure injury prevention—can significantly influence outcomes. Internal factors including impaired circulation, dry skin, and water-electrolyte imbalances, as well as complexities related to medical devices and existing comorbidities, further compound this risk. Therefore, identifying and understanding these vulnerabilities is crucial for implementing effective preventative strategies to protect this sensitive population from potential tissue damage, ensuring their health and well-being during critical periods of development.

Defining Characteristics of the NANDA-I Diagnosis

The NANDA-I diagnosis "Risk for neonatal pressure injury" is identified by its defining characteristics. These are explained below:

Piel seca La piel seca es un indicativo crítico del riesgo de lesión por presión, ya que la deshidratación puede comprometer la integridad cutánea y hacerla más vulnerable a lesiones. La piel, cuando no tiene suficiente humedad, pierde su elasticidad y se vuelve más propensa a las fisuras y erosiones. En neonatos, esto es especialmente importante, ya que su piel es más delgada y menos resistente a la fricción y la presión. La evaluación regular del estado de hidratación y la aplicación de humectantes adecuados son medidas esenciales en la prevención de lesiones cutáneas en neonatos.
Hipertemia La hipertemia, o aumento de la temperatura en la piel, es un signo de inflamación que puede preceder a las lesiones por presión. Este aumento de temperatura puede ser resultante de una circulación sanguínea inadecuada o de la presión prolongada en un área particular, lo que restringe el flujo sanguíneo y lleva a un aporte insuficiente de oxígeno a los tejidos. La detección temprana de la hipertemia en áreas de mayor riesgo permite a los profesionales de la salud intervenir rápidamente mediante el cambio de posiciones y la aplicación de tratamientos tópicos para aliviar la presión.
Circulación deteriorada Una circulación sanguínea deficiente puede resultar en una oxigenación insuficiente de los tejidos, lo que magnifica el riesgo de daño tisular en neonatos. La reducción del flujo sanguíneo a áreas específicas puede provocar una acumulación de productos de desecho metabólico, lo que a su vez aumenta el riesgo de isquemia y necrosis. La monitorización constante de la perfusión y el uso de técnicas de posicionamiento adecuadas son cruciales para prevenir la aparición de heridas por presión en neonatos con riesgo.
Movilidad física comprometida La movilidad física limitada en neonatos, ya sea por condiciones médicas o por el entorno, puede contribuir significativamente al riesgo de lesiones por presión. La falta de movimiento puede incrementar la presión en ciertas áreas del cuerpo, haciendo que estas zonas sean más propensas a desarrollarse lesiones por compresión prolongada. La identificación temprana de neonatos con movilidad restringida, junto con la implementación de un plan de cuidados que incluya cambios frecuentes de posición y ejercicios pasivos, es vital para prevenir complicaciones.
Volumen de líquidos inadecuado Un volumen de líquidos insuficiente afecta la hidratación y la nutrición de la piel y los tejidos subyacentes, lo que puede comprometer su integridad. En neonatos, la correcta hidratación es esencial para mantener la salud cutánea, ya que una mala hidratación puede llevar a la piel quebradiza y seca, aumentando el riesgo de lesiones por presión. Monitorizar la ingesta de líquidos y la diuresis es fundamental para asegurar que los neonatos estén adecuadamente hidratados y así se minimice el riesgo de desarrollo de lesiones cutáneas.
Desequilibrio agua-electrolitos Un desequilibrio en los niveles de agua y electrolitos puede alterar la función celular y la integridad de la piel, propiciando un entorno propenso a las lesiones por presión. Estos desequilibrios pueden provocar edema, aumento de la fragilidad de los tejidos y cambios en la sensación y la respuesta del cuerpo a la presión. La evaluación regular de los electrolitos en neonatos y la implementación de intervenciones apropiadas para os equilibrar son cruciales para mantener la integridad cutánea y prevenir daños.

Related Factors (Etiology) of the NANDA-I Diagnosis

The etiology of "Risk for neonatal pressure injury" is explored through its related factors. These are explained below:

Microclima alterado entre la piel y la superficie de soporte Altered microclimates can create an environment conducive to moisture accumulation, which softens the skin and increases friction. This combination enhances the likelihood of skin breakdown, particularly in the delicate skin of neonates, which is thinner and more susceptible to pressure injuries. Effective management of this microclimate is critical to preventing injuries, necessitating the use of breathable materials to facilitate air circulation and reduce moisture accumulation.
Acceso inadecuado a equipos apropiados The absence of appropriate care equipment, such as specialized mattresses or pressure-relieving devices, limits caregivers' ability to provide optimal care. This lack of access can hinder early interventions that are vital in mitigating pressure against bony prominences. It emphasizes the need for healthcare systems to ensure that neonatal units are well-equipped to prevent pressure injuries effectively.
Acceso inadecuado a servicios de salud apropiados Limited access to adequate healthcare services can exacerbate the risk of pressure injuries due to insufficient monitoring and care. Inadequate healthcare can lead caregivers to neglect signs of skin breakdown, which requires timely interventions. Access to specialized neonatal care is essential in reducing the incidence of avoidable pressure injuries through regular assessment and prompt treatment.
Acceso inadecuado a suministros apropiados A lack of essential supplies such as barrier creams, dressings, or moisture-wicking fabrics can hinder effective care routines. These materials are critical in preventing skin injury by providing protective layers against external forces. The unavailability of such resources compromises caregiver efforts to implement preventive strategies, increasing the risk for pressure injuries.
Conocimiento inadecuado del cuidador sobre métodos apropiados para estabilización de dispositivos Inadequate caregiver knowledge regarding the proper stabilization of medical devices can lead to incorrect positioning and placement, increasing pressure on soft tissues and resulting in skin damage. Educating caregivers on device management and the importance of repositioning is paramount in reducing this risk.
Conocimiento inadecuado del cuidador sobre el uso apropiado de materiales adhesivos Improper application of adhesive materials by caregivers can lead to skin trauma. The incorrect use of tapes and adhesives can damage the fragile neonatal skin, particularly if they are not appropriately designed for use with newborns. Training caregivers to use these materials correctly will mitigate the risk of adhesive-related skin injuries.
Conocimiento inadecuado del cuidador sobre factores modificables A lack of understanding regarding modifiable risk factors (such as humidity levels and pressure points) prevents caregivers from applying effective preventive strategies. Educating staff about how environmental factors impact skin integrity can empower them to implement changes that reduce injury risks.
Conocimiento inadecuado del cuidador sobre estrategias de prevención de lesiones por presión If caregivers lack knowledge about established pressure injury prevention strategies, such as repositioning protocols or skin monitoring, they may inadvertently overlook protective measures. Comprehensive training is essential to ensure that caregiver practices align with current best practices in neonatal care.
Nivel de humedad en la piel inapropiado Abnormal skin moisture levels, whether excessive or inadequate, can lead to increased skin fragility. Too much moisture makes the skin more susceptible to maceration and breakdown, while insufficient moisture can cause dryness and cracking. Maintaining optimal hydration levels is crucial in preserving skin integrity and preventing pressure injuries.
Aumento de la magnitud de la carga mecánica An increase in mechanical load on the skin, such as prolonged pressure from devices or surfaces, compromises skin integrity. It can lead to localized hypoxia and subsequent tissue necrosis if not addressed. Awareness of loads should result in proactive measures like regular repositioning to alleviate pressure.
Presión sobre prominencias óseas Continuous pressure on bony prominences from inadequate padding or poor positioning can significantly elevate the risk for skin damage. The reliance on high-risk areas for weight distribution in neonates necessitates more diligent repositioning practices and the utilization of protective devices to cushion these vulnerable spots.
Fuerzas de cizallamiento Shear forces, particularly during patient movement or repositioning, can cause tearing and bruising of the skin. Such forces can occur when a neonate is moved across a surface without lifting. Caregiver education on techniques that minimize shear during handling is vital for preserving skin health and preventing injuries.
Fricción en la superficie Friction from surfaces can contribute to skin abrasions and predispose neonates to pressure injuries. Healthcare settings must utilize appropriate linens and ensure that caregiver techniques minimize friction during movements. Implementation of sliding sheets or appropriate dressing techniques is essential in reducing risk.
Carga mecánica sostenida Sustained mechanical load on skin without relief leads to tissue ischemia and potential necrosis. This underscores the importance of a consistent schedule for repositioning infants and utilizing pressure-relieving devices to counteract prolonged pressure exposures.
Uso de ropa de cama con propiedades inadecuadas de absorción de humedad Bed linens that lack moisture-wicking properties can contribute to a damp environment, exacerbating the risk of skin breakdown. Utilizing specialized linens can help in managing moisture levels and should be a standard practice in neonatal care environments to prevent pressure injuries.

At-Risk Population for the NANDA-I Diagnosis

Certain groups are more susceptible to "Risk for neonatal pressure injury". These are explained below:

Neonates with Low Birth Weight
Newborns who are classified as low birth weight (typically under 2500 grams) are at a significantly heightened risk for pressure injuries due to several factors. Their skin is often thinner and more fragile, lacking the robust protective mechanisms seen in healthier, larger infants. Furthermore, low birth weight can be associated with immature skin development and inadequate subcutaneous fat, providing less cushioning over bony prominences. This inherent vulnerability, combined with other variables such as limited mobility and prolonged positioning during care, predisposes these infants to the development of pressure injuries.
Neonates Born at Less Than 32 Weeks of Gestation
Premature infants, especially those born before 32 weeks of gestation, are particularly susceptible due to their underdeveloped physiological systems. The often fragile skin of these neonates is not only thinner but also lacks the necessary moisture levels and lipid barrier to protect against friction and shear forces. These infants may experience disrupted blood flow and delayed wound healing, exacerbating their risk for pressure injuries. Additionally, they frequently experience extended periods of immobility in incubators or cribs, further increasing the likelihood of skin breakdown.
Neonates with Prolonged ICU Stays
Infants who undergo extended stays in neonatal intensive care units (NICUs) frequently face dual challenges that heighten their risk of pressure injuries. First, the prolonged immobility—often a necessity for their health—limits blood circulation to critical areas, resulting in tissue ischemia. Second, the medical equipment and supportive devices used in the NICU can contribute to skin irritations and pressure points. The stress of illness often leads to compromised nutritional status, which can slow healing and further complicate the skin’s ability to withstand pressure, making them particularly vulnerable to injury.
Neonates in Intensive Care Settings
This population is exposed to a unique set of risks by being placed in intensive care settings. The continuous monitoring and use of medical devices impose risk factors like immobility and skin friction. Moreover, these neonates may suffer from underlying health issues requiring sedative medications, which further reduce their ability to change positions. Coupled with the environmental conditions of an ICU—such as high humidity from respiratory support equipment and the use of adhesive devices—these factors contribute to an increased risk of skin breakdown and pressure injuries. Ongoing assessments and interventions are critical in this setting to proactively manage and mitigate these risks.

Associated Conditions for the NANDA-I Diagnosis

The diagnosis "Risk for neonatal pressure injury" can coexist with other conditions. These are explained below:

Impaired Skin Integrity - The neonatal skin is thinner and more fragile than adult skin, making it more susceptible to pressure injuries. Immature skin lacks the fully developed stratum corneum, which serves as a primary barrier against environmental factors. This predisposition means that any sustained pressure from lying in one position or from devices can lead to local ischemia and subsequent skin breakdown.
Nutrition-Related Conditions
- Anemia - A decrease in red blood cells limits oxygen delivery to tissues, adversely affecting oxygenation and nutrient delivery to the skin. Poor tissue perfusion from anemia can significantly augment the risk of pressure injuries since the skin and underlying tissues are less capable of repairing themselves.
- Decreased Serum Albumin Levels - Low levels of albumin are indicative of malnutrition, which directly impacts tissue repair and skin health. When albumin levels are low, edema can occur, leading to increased skin tension and pressure, heightening the risk for pressure ulcers.
- Deficiencies Related to Prematurity - Neonates born prematurely may struggle to obtain adequate nutrition, which is crucial for skin development and repair. Deficiencies in essential nutrients can compromise the structural integrity of the skin, making it more vulnerable to ulceration and injury.
Circulatory and Oxygenation Conditions
- Decreased Tissue Perfusion - Poor perfusion is a common issue in preterm infants and can result from various factors, including low blood pressure and compromised cardiac output. When perfusion is inadequate, the risk of hypoxia in the skin and surrounding tissues rises, leading to a higher incidence of pressure injuries.
- Decreased Tissue Oxygenation - Insufficient oxygen availability can lead to tissue necrosis, especially in areas subjected to sustained pressure. Damage occurs as cells fail to regenerate efficiently under hypoxic conditions, propelling the risk of pressure injury development.
Mechanical Factors
- Immobility - Limited mobility increases the likelihood of prolonged pressure on bony prominences. This lack of movement contributes to pressure injury risk by preventing the natural redistribution of body weight, resulting in constant pressure on the same areas and inhibiting circulation.
- Medical Devices - The use of medical devices such as intravenous lines or monitors can create additional pressure and friction on the skin. These devices may trap moisture and create areas of localized pressure, leading to the breakdown of the skin's integrity.
Infection and Systemic Health
- Sepsis - The presence of infection can significantly compromise skin health, as it diverts energy and nutrients to the immune response, hindering the body's ability to maintain skin integrity. Additionally, systemic inflammation can result in increased capillary permeability, causing edema and reducing the skin's resilience against pressure injuries.
- Significant Comorbidities - Conditions such as congenital heart defects or chronic lung disease can exacerbate the risk of pressure injury by creating additional challenges in maintaining oxygenation and overall health status in neonates. These comorbidities can complicate treatment and management strategies for preventing pressure injuries.
Surgical and Procedural Factors
- Prolonged Duration of Surgical Procedures - Extended surgical time can increase the risk of pressure injuries as the patient remains in a static position for an extended period, amplifying pressure on certain skin areas and limiting perfusion.
- Surgical Interventions - Any entry to the body via surgical methods has implications for skin integrity. The manipulation and incision can disrupt normal skin barriers, and care must be taken due to the increased risk of pressure injuries in the postoperative period.

NOC Objectives / Expected Outcomes

For the NANDA-I diagnosis "Risk for neonatal pressure injury", the following expected outcomes (NOC) are proposed to guide the evaluation of the effectiveness of nursing interventions. These objectives focus on improving the patient's status in relation to the manifestations and etiological factors of the diagnosis:

Skin Integrity
This outcome is crucial as it directly measures the condition of the skin, which is at risk for injury in neonates. Monitoring skin integrity allows healthcare providers to identify early signs of pressure injuries, enabling timely intervention and prevention strategies to be implemented.
Activity Tolerance
Assessing activity tolerance is important as it helps to determine the neonate’s ability to reposition or move, which is essential in preventing pressure injuries. A neonate who demonstrates good activity tolerance is less likely to develop immobilization-related pressure injuries, highlighting the need for movement and stimulation.
Nutrition: Nutritional Status
An adequate nutritional status is vital for skin health and healing. This outcome focuses on ensuring that the neonate receives sufficient nutrition to support skin integrity and repair processes. Close monitoring of nutritional status helps to prevent deterioration that may lead to pressure injuries.
Comfort: Pain Level
Evaluating pain level is relevant because discomfort can prevent a neonate from assuming optimal positions that relieve pressure points. Understanding and managing pain not only promotes comfort but also enhances the neonate’s ability to reposition themselves, thus reducing the risk of pressure injuries.

NIC Interventions / Nursing Care Plan

To address the NANDA-I diagnosis "Risk for neonatal pressure injury" and achieve the proposed NOC objectives, the following nursing interventions (NIC) are suggested. These interventions are designed to treat the etiological factors and manifestations of the diagnosis:

Skin Care: Prevention
This intervention involves implementing strategies to maintain skin integrity, such as regular assessment of skin condition, optimizing moisture levels, and using protective barriers. By preventing moisture accumulation and protecting vulnerable areas, this intervention helps to reduce the risk of pressure injuries in neonates.
Positioning: Frequent Repositioning
This intervention entails regularly changing the position of the neonate to alleviate pressure on bony prominences. Frequent repositioning ensures that no area remains under pressure for extended periods, thereby enhancing blood circulation and reducing the likelihood of pressure injuries.
Education: Family/Patient
This intervention focuses on educating parents and caregivers about the signs of pressure injury formation and the importance of frequent positioning and skin care. Empowering the family with knowledge promotes comprehensive care and ensures proactive measures are taken to minimize risk.
Monitoring: Skin
This intervention involves the systematic assessment of the neonate's skin for early signs of pressure injury. By closely monitoring skin condition, healthcare providers can identify issues early and implement timely interventions to prevent further deterioration.

Detailed Nursing Activities

The NIC interventions for the NANDA-I diagnosis "Risk for neonatal pressure injury" are composed of specific activities that nursing staff carry out to provide effective care. Below, examples of activities for the key identified interventions are detailed:

For the NIC Intervention: Skin Care: Prevention

Assess the neonate's skin condition at least every shift to identify any early signs of pressure injury, allowing for timely intervention.
Apply moisture barrier creams to areas at risk of breakdown, such as the sacrum and heels, to protect the skin from moisture and friction.
Keep the skin clean and dry by performing frequent diaper changes and using gentle cleansers that do not strip natural oils.
Utilize soft, non-irritating linens and clothing to minimize friction and irritation against the skin.

For the NIC Intervention: Positioning: Frequent Repositioning

Reposition the neonate every 1-2 hours to alleviate pressure on bony prominences and promote circulation.
Use specialized positioning aids such as foam wedges or cushions to maintain optimal positioning and reduce direct pressure.
Educate and involve the family in repositioning techniques to promote consistency in care and minimize risk.
Document the position changes and any skin assessments in the neonate's chart to track effectiveness and collaborate with the healthcare team.

For the NIC Intervention: Monitoring: Skin

Conduct systematic skin assessments at least every shift, focusing on areas of highest risk for pressure injury, such as the sacrum and heels.
Implement a pressure injury risk assessment tool upon admission and reassess regularly to track changes in skin condition.
Notify the healthcare team immediately of any signs of skin breakdown or pressure injuries to facilitate prompt treatment.
Educate the family on signs of skin integrity issues and ensure they understand the importance of reporting any concerns.

Practical Tips and Advice

To more effectively manage the NANDA-I diagnosis "Risk for neonatal pressure injury" and improve well-being, the following suggestions and tips are offered for patients and their families:

Change Positions Regularly

To reduce pressure on vulnerable areas, change your baby's position at least every two hours. This promotes good circulation and helps prevent skin breakdown, particularly in areas like the back, heels, and buttocks.
Use Soft, Supportive Bedding

Ensure that your baby is placed on a soft surface like a padded mattress or specialized pressure-relieving mattress. This will provide better cushioning and help to distribute body weight evenly, reducing pressure on sensitive skin.
Keep the Skin Clean and Dry

Regularly check and change diapers to prevent moisture build-up, which can lead to skin irritation. Clean your baby's skin gently with mild soap and ensure the area is thoroughly dried before redressing.
Use Barrier Creams

Apply a barrier cream or ointment on parts of the skin that are prone to pressure injuries, such as the buttocks, to protect against moisture and friction. This is especially important if your baby spends a lot of time on their back.
Monitor for Skin Changes

Regularly inspect your baby’s skin, especially areas of pressure, for any signs of redness, swelling, or breakdown. Early detection of skin changes allows for prompt intervention, reducing the risk of developing a pressure injury.
Encourage Movement and Activity

When appropriate, gently encourage your baby to move or engage in supervised tummy time. This not only strengthens their muscles but also helps to relieve pressure on specific body areas.
Maintain Optimal Nutrition and Hydration

Ensure your baby is receiving adequate nutrition and hydration, according to their dietary needs. Good nutrition supports skin health and overall well-being, making it more resilient against injury.

Practical Example / Illustrative Case Study

To illustrate how the NANDA-I diagnosis "Risk for neonatal pressure injury" is applied in clinical practice and how it is addressed, let's consider the following case:

Patient Presentation and Clinical Context

A 2-week-old male infant, born prematurely at 28 weeks of gestation, currently weighs 1.5 kg and is being treated in the neonatal intensive care unit (NICU) for respiratory distress. The infant has been on a ventilator for the past week due to poor oxygenation. His limited mobility and prolonged periods of supine positioning during ventilation have raised concerns regarding skin integrity, leading to a comprehensive nursing assessment for potential risk factors related to pressure injuries.

Nursing Assessment

During the assessment, the following significant data were collected:

Fragile skin integrity: Observed pale, thin skin that is easily marked with indentation from any external pressure.
Positioning: The infant has been in a supine position for extended periods, with limited repositioning due to ventilator support.
History of low birth weight: Weighing 1.5 kg, contributing to overall skin fragility.
Presence of medical devices: Continuous use of suction devices and IV lines creating potential localized pressure points.
Inadequate nutrition: Enteral feeding initiated, but tolerance is currently poor, which affects skin health and healing potential.

Analysis and Formulation of the NANDA-I Nursing Diagnosis

The analysis of the assessment data leads to the identification of the following nursing diagnosis: Risk for neonatal pressure injury. This conclusion is based on the infant’s fragile skin integrity, limited mobility due to prolonged supine positioning, presence of medical devices that exert pressure, and a history of low birth weight. These factors collectively increase the likelihood of developing pressure injuries, justifying the need for proactive nursing interventions.

Proposed Care Plan (Key Objectives and Interventions)

The care plan will focus on addressing the "Risk for neonatal pressure injury" diagnosis with the following priority elements:

Objectives (Suggested NOCs)

Maintain skin integrity and prevent pressure injuries.
Optimize nutrition to support skin health and healing.

Interventions (Suggested NICs)

Positioning:
- Reposition the infant every 2 hours to alleviate pressure on specific body areas.
- Utilize special mattresses and cushions to support skin integrity.
Skin Care:
- Monitor skin condition and apply barrier creams to at-risk areas.
- Educate staff on appropriate skin care techniques to prevent injury.

Progress and Expected Outcomes

With the implementation of the proposed interventions, it is expected that the patient will show improvement in skin condition, including the absence of pressure injuries and maintenance of skin integrity. Adequate repositioning and skin care will minimize the risk factors, promoting overall skin health and readiness for further growth. Continuous monitoring will allow evaluation of the plan's effectiveness.

Frequently Asked Questions (FAQ)

Below are answers to some frequently asked questions about the NANDA-I diagnosis "Risk for neonatal pressure injury":

What does 'Risk for neonatal pressure injury' mean?

'Risk for neonatal pressure injury' refers to the potential for newborns to develop skin damage due to prolonged pressure on specific areas of their body, especially in premature or critically ill infants who may have fragile skin.

Who is at risk for neonatal pressure injuries?

Preterm infants, low-birth-weight infants, and babies with certain medical conditions such as respiratory distress are at higher risk for neonatal pressure injuries due to their delicate skin and limited mobility.

How can neonatal pressure injuries be prevented?

To prevent neonatal pressure injuries, ensure regular repositioning of the baby, use pressure-relieving devices, maintain skin hygiene, and keep the skin moisturized to enhance skin integrity.

What are the signs of a neonatal pressure injury?

Signs of a neonatal pressure injury may include redness, swelling, or open sores on the skin, particularly over bony areas such as the heels, sacrum, or the back of the head.

How is a neonatal pressure injury treated?

Treatment for neonatal pressure injuries includes gentle cleansing of the area, applying appropriate dressings, ensuring an appropriate environment for healing, and addressing any underlying risks to promote skin integrity.