Pressure Ulcer Prevention 1 Algorithm
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Pressure Ulcer Prevention 1 Algorithm *Braden Scores: At Risk: 15-18 Moderate Risk: 13-14 High Risk: 10-12 Very High Risk: < 9 Admission Skin assessment (including history) Head to toe inspection: Is there skin injury or pressure ulcer? No Yes Develop an individualized care plan for treating and preventing further skin breakdown 2-4 If patient has a pressure ulcer on admission: Notify admitting physician and document in LDA group “Pressure injury/ulcer” Daily pressure ulcer risk assessment; use Braden Scale. Complete holistic review for risk fa Is there risk for skin breakdown or pressure ulcer? *Braden score < 18 or other risk factors Develop target interventions 2-4 to address each risk area and include in the individualized plan of care (“Pressure ulcer prevention” secondary care plan) Review outcomes of plan and interventions Braden score > 18 Daily: • Skin Inspection •Braden Scale •Holistic review of risk factors Braden Scale Risk Stratification Automatic consult goes to Dietitians: Braden score < 14 and nutrition subscore is 1-2 for 3 consecutive days NIP policy/order set No Yes Place “iceberg” magnet on patient’s door to identify risk* Mobility Activity Deficit Moisture/ Incontinence Nutritiona l Deficit 1 Adapted from Armstrong DG et al: New opportunities to improve pressure ulcer prevention and treatment, Adv Skin Wound Care 21(10):469-78, 2008. 2 Monahan FD: Phipps’ medical-surgical nursing: health and illness perspective, ed. 8, St. Louis, 2007, Mosby/Elsevier. 3 Perry AG, Potter PA: Clinical nursing skills & technique, ed. 6, St. Louis, 2006, Mosby/Elsevier. 4 Tucker SM et al: Patient care standards: collaborative planning and nursing interventions, ed. 7, St. Louis, 2007, Mosby/Elsevier. 5 MN Hospital Association, 2/2007, Road Map to a Comprehensive Skin Safety Program Yes Yes Yes SKIN Bundle 5 S = Skin Inspection & Risk Assessment K = Keep pressure off – minimize pressure, friction, shear I = Incontinence/moisture skin protection N = Nutrition is optimized Review outcomes of plan and interventions Skin inspection Q shift if Braden < 12 ; otherwise daily If pressure injury/ulcer is hospital acquired, document in LDA group and submit PVSR
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Admission. Skin assessment (including history). Develop an individualized care plan for treating and preventing further skin breakdown 2-4 If patient has a pressure ulcer on admission: Notify admitting physician and document in LDA group “Pressure injury/ulcer”. - PowerPoint PPT Presentation
Transcript of Pressure Ulcer Prevention 1 Algorithm
Pressure Ulcer Prevention1
Algorithm
*Braden Scores:At Risk: 15-18Moderate Risk: 13-14High Risk: 10-12Very High Risk: < 9
Admission
Skin assessment (including history)
Head to toe inspection: Is there skin injury or
pressure ulcer?
No
Yes
Develop an individualized care plan for treating and preventing further skin breakdown2-4
If patient has a pressure ulcer on admission: Notify admitting physician and document in LDA group “Pressure injury/ulcer”
Daily pressure ulcer risk assessment; use Braden Scale. Complete holistic review for risk factors
Is there risk for skin breakdown or pressure ulcer?
*Braden score < 18 or other risk factors
Develop target interventions2-4 to address each risk area and include in the individualized plan of care (“Pressure ulcer prevention” secondary care plan)Review outcomes of plan and interventions
Braden score > 18
Daily:• Skin Inspection•Braden Scale•Holistic review of risk factors
Braden Scale RiskStratification
Automatic consult goes to Dietitians: Braden score < 14 and nutrition subscore is 1-2 for 3 consecutive days NIP policy/order set
NoYes
Place “iceberg” magnet on patient’s door to identify risk*
Mobility Activity Deficit
Moisture/ Incontinence
Nutritional Deficit
1Adapted from Armstrong DG et al: New opportunities to improve pressure ulcer prevention and treatment, Adv Skin Wound Care 21(10):469-78, 2008.2 Monahan FD: Phipps’ medical-surgical nursing: health and illness perspective, ed. 8, St. Louis, 2007, Mosby/Elsevier.3Perry AG, Potter PA: Clinical nursing skills & technique, ed. 6, St. Louis, 2006, Mosby/Elsevier.4 Tucker SM et al: Patient care standards: collaborative planning and nursing interventions, ed. 7, St. Louis, 2007, Mosby/Elsevier.5MN Hospital Association, 2/2007, Road Map to a Comprehensive Skin Safety Program
Yes YesYes
SKIN Bundle5
S = Skin Inspection & Risk AssessmentK = Keep pressure off – minimize pressure, friction, shearI = Incontinence/moisture skin protectionN = Nutrition is optimized
Review outcomes of plan and interventions
Skin inspection Q shift if Braden < 12 ; otherwisedaily
If pressure injury/ulcer is hospitalacquired, document in LDA group
and submit PVSR
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