1. To promote healthy intact skin.
  2. To educate patient and/or significant others about pressure ulcer prevention.
  3. 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.
  4. RN or designated skin care provider may determine the need for and implement appropriate skin care treatment.


RN, LPN, CNA - all aspects.



  1. Perform Braden scale on admission, quarterly, and significant change in condition.
  2. Visually assess all bony prominences (heels, ankles, hips, sacrum, occiput, ears, shoulders, elbows) at least daily.
  3. Assess for signs and symptoms of altered hydration and nutrition.
  4. Assess mobility and activity.
  5. Assess for fecal or urinary incontinence.
  6. Assess educational needs.


  1. Reduce or eliminate pressure, shear, friction, and moisture.
  2. Provide adequate nutrition and hydration.
  3. Promote optimum mobility and activity.
  4. Prevent skin breakdown.
  5. Provide education.


  1. 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.
  2. Keep head of bed elevated to less than 30 degrees except at meal time.
  3. Use knee gatch when head of bed is elevated.
  4. Use lift sheet.
  5. Use device such as pillows and foam wedges to prevent direct contact between bony prominence (such as knees and ankles).
  6. Utilize overhead trapeze if patient is able to use.
  7. Raise heels off the bed with pillow lengthwise to support legs.
  8. Limit sitting time to one hour at a time, whether in bed, chair, or wheelchair.
  9. Encourage patient to shift their weight every 15 minutes while in wheelchair.
  10. . Place pressure reduction device on the bed and chair or wheelchair.
  11. . DO NOT use donut type devices.
  12. . Use proper positioning, transferring, and turning techniques.
  13. . Inspect skin at least once a day.
  14. . Individualize bathing schedule. Avoid hot water. Use a mild cleansing agent.
  15. . Use lubricants to reduce friction injuries.
  16. . Avoid massage over bony prominences.
  17. . Minimize environmental factors such as low humidity and cold air. Use moisturizers for    dry skin.
  18. . Evaluate and manage urinary and/or fecal incontinence.
  19. . Cleanse skin at time of soiling and at routine intervals.
  20. . Use protective barrier on skin if incontinent.
  21. . Use personal perineal cleanser for frequent stools.
  22. . Consult dietitian to assist with nutritional assessment and planning. Implement recommendations.
  23. . Obtain lab tests as recommended by dietitian and/or primary care provider.
  24. . Encourage 8 - 8 oz. glasses of fluids per day unless contraindicated.
  25. . Consult physical/occupational therapist regarding mobility and range of motion exercises.
  26. . Provide range of motion exercises BID.
  27. . Provide patient education materials.


  1. Monitor skin surfaces daily.
  2. Document on appropriate facility form.

ACWCP - 1998