MULTIDISCIPLINE CARE PLAN - MCP
SKIN CARE PROTOCOL BRADEN SCORE 16 OR LESS

DATE  

PROBLEM OR 
NEED

MEMBERS GOAL

STAFF APPROACHES/IMPLEMENTATION

RESPONSIBLE
DISCIPLINE
  Skin Care Alert!
At risk for
impaired skin
integrity.		 Patient will have health intact
skin by:

 

 1.  Implement a turning schedule; minimum of every 2 hours.                                            

 

 

 
    a.  reducing or elimating
pressure, shear, friction and
moisture.		 2.  When side-lying position is used a 30 degree turning position should be used:
avoid positioning directly on trochanter.		  
    b.  Providing adequate nutrition
and hydration.		 3.  Place pressure reduction device on the bed, chair or wheelchair.  
    c.  Promoting optimum mobility
and activity.		 4.  Use device such as pillows or foam wedges to prevent direct contact between
bony prominence.		  
    d.  Providing education to patient. 5.  Raise heels off bed with pillow lengthwise to support legs.  
      6.  Use lift sheet.  
      7.  Utilize overhead trapeze if patient is able to use.  
      8.  DO NOT use donut type devices.  
      9.  Keep head of bed in lowest degree of elevation consistent with medical condition
(optimum is less than 30 degrees except at mealtime).		  
      10. Use knee gatch when head of bed is elevated.  
      11.  Limit sitting time to one hour at a time, whether in bed, chair or wheelchair.  
      12. Encourage patient to shift their weight every 15 minute while in wheelchair.  
      13. Inspect skin at least once/day.  
      14. Avoid massage over bony prominence.  
      15. Provide ROM excercise BID.  
      16.  Consult PT/OT regarding mobility needs as indicated.  
      17. Individualize bathing schedule.  Avoid hot water.   Use mild cleansing agent.  
      18. Use lubricants to reduce friction injuries; moisturizers for dry skin.  
      19. Evaluate and manage urinary and/or fecal incontinence.  
      20. Cleanse skin at time of soiling and PRN.  
      21. Use protective barrier on skin if incontinent.  
      22. Use personal perineal cleanser for frequent stools.  
      23.  Consult dietician to assist with nutritional assessment and planning.  
      24. Obtain lab tests as recommended by dietician and/or MD.  
      25. Encourage 8 - 8 oz glasses of fluids per day unless contraindicated.  
      26.  Provide patient education materials as indicated.  
1.  Nursing
Signatures:		     2.  Physical Therapy   3.  Dietary   4.  Activities   5.  Social Services   6.  Spiritual   7.  Member
1. _____________   2. ______________   3. ____________   4. ____________   5. ____________   6. __________   7. ___________
1. _____________   2. ______________   3. ____________   4. ____________   5. ____________   6. __________   7. ___________

MEMBERS NAME: _______________________________		  
  DATE: ________		   REVIEW DATE: _____________ R# ___________

ACWCP - 1998