Updated September 2011

CleanseMoisturizeProtectBe Gentle

Complete and document a skin assessment on admission and daily

Note whether or not wounds and pressure ulcers are present on admission (POA)

Complete the Pressure Ulcer Risk Assessment Tool: The Braden Scale

Document and stage all pressure ulcers using the NPUAP* Staging system

*National Pressure Ulcer Advisory Panel

◦ The Braden Scale score will help identify patients at risk for developing pressure ulcers

◦ Score of 12 or less indicates your patient is at high risk for pressure ulcer formation

◦ Initiate interventions targeted at the areas in which your patient achieved lower scores

Measure and document wounds when discovered and every Wednesday. Document length, width, and depth in cm

Document appearance of wound bed, odor, drainage, and condition of surrounding skin

Consider a multidisciplinary approach to include a dietitian, physical therapist, or an occupational therapist to optimize wound healing

 Repositioning

 Position patients off of affected area(s) if pressure ulcers are present  Position patients at a 30-degree angle when on their sides

Avoid raising the head of the bed (HOB) higher than 30 degrees

 Use pillow between knees and ankles when on their sides

 Use safe patient handling equipment to move patients

 Apply barrier cream to buttocks if patient is incontinent of urine or stool

Float heels off the bed surface

All interventions implemented Barriers to implementation (for example, a

patient’s unstable hemodynamics may make it impossible to reposition him/her as often as is needed for skin integrity)

Patient and caregiver’s willingness to accept interventions

Patient and caregiver education provided regarding skin integrity

Every nurse should initiate the standing skin care orders for Stage I pressure ulcers Stage II pressure ulcers Skin tears

Standing Skin Care Orders are located on every department and can also be found in the section entitled “Reference Documents” on every computer

1. Click on MCHS intranet icon (soon to be Cone Health icon)

2. Click on Resources3. Click on Reference Documents4. Click on Clinical Resources5. Click on Wound Ostomy Care

Involves inspecting the skin of every patient in our hospitals on the same day to provide an accurate “snap shot” of the number of patients who have pressure ulcers

Quarterly measuring of PUP is a requirement for all Magnet™ hospitals

Hospital Acquired Pressure Ulcers are considered “Never Events” by The Joint Commission

Cone Health’s Goal= 0%

This is an opportunity for you to participate in research that improves patient care

Wound Ostomy Continence (WOC) nurse consults require a physician’s order

Appropriate consultations include:

Stage III or IV pressure ulcers

Patients with new ostomies

Patients with established ostomies who are having problems

New placement of negative pressure wound therapy

Complex lower extremity wounds