PRESSURE ULCER PREVENTION POLICY AND PROCEDURE
- To promote healthy intact skin.
- To educate patient and/or significant others about pressure ulcer prevention.
- At risk patients will be identified by use of Braden scale. Patient with score of 16 or
below will be considered at risk and the following procedure will be implemented.
- RN or designated skin care provider may determine the need for and implement appropriate
skin care treatment.
RN, LPN, CNA - all aspects.
- Perform Braden scale on admission, quarterly, and significant change in condition.
- Visually assess all bony prominences (heels, ankles, hips, sacrum, occiput, ears,
shoulders, elbows) at least daily.
- Assess for signs and symptoms of altered hydration and nutrition.
- Assess mobility and activity.
- Assess for fecal or urinary incontinence.
- Assess educational needs.
- Reduce or eliminate pressure, shear, friction, and moisture.
- Provide adequate nutrition and hydration.
- Promote optimum mobility and activity.
- Prevent skin breakdown.
- Provide education.
- Implement written turning schedule, changing position at least every 2 hours while in
bed. When side-lying position is used, a 30 degree turning position should be used.
- Keep head of bed elevated to less than 30 degrees except at meal time.
- Use knee gatch when head of bed is elevated.
- Use lift sheet.
- Use device such as pillows and foam wedges to prevent direct contact between bony
prominence (such as knees and ankles).
- Utilize overhead trapeze if patient is able to use.
- Raise heels off the bed with pillow lengthwise to support legs.
- Limit sitting time to one hour at a time, whether in bed, chair, or wheelchair.
- Encourage patient to shift their weight every 15 minutes while in wheelchair.
- . Place pressure reduction device on the bed and chair or wheelchair.
- . DO NOT use donut type devices.
- . Use proper positioning, transferring, and turning techniques.
- . Inspect skin at least once a day.
- . Individualize bathing schedule. Avoid hot water. Use a mild cleansing agent.
- . Use lubricants to reduce friction injuries.
- . Avoid massage over bony prominences.
- . Minimize environmental factors such as low humidity and cold air. Use moisturizers for
- . Evaluate and manage urinary and/or fecal incontinence.
- . Cleanse skin at time of soiling and at routine intervals.
- . Use protective barrier on skin if incontinent.
- . Use personal perineal cleanser for frequent stools.
- . Consult dietitian to assist with nutritional assessment and planning. Implement
- . Obtain lab tests as recommended by dietitian and/or primary care provider.
- . Encourage 8 - 8 oz. glasses of fluids per day unless contraindicated.
- . Consult physical/occupational therapist regarding mobility and range of motion
- . Provide range of motion exercises BID.
- . Provide patient education materials.
- Monitor skin surfaces daily.
- Document on appropriate facility form.
ACWCP - 1998