Pressure ulcer prevention pathway

Admission

Thorough skin
Assessment
(including history)

Is there skin breakdown

Or pressure ulcer

Yes

No

Develop an individualized
care plan for treating and
Preventing further
Skin breakdown.
Consult to wound care.
Inform the Physician.

Assess pressure ulcer risk each shift:

Braden Scale
Complete holistic review for risk factors
Complete Documentation

Braden score 19 or more

Reassess the skin and
pressure ulcer risk each shift

No

Is there risk for

skin breakdown or
pressure ulcer?

Yes

Braden score 18 or less

Consult to wound care
Dietitian consult

Turn

or reposition at least every 2 hours, or more

frequently if needed.
Dietitian consult if intake/output suboptimal.
Relieve pressure over boney prominences.
Keep patient as flat as possible during repositioning
to reduce friction/shear.
Use appropriate equipment during repositioning/turning.
Use pressure reduction/relief mattress/bed.
Encourage patient to shift weight q15 minutes when sitting.
Preventive skin care; avoid hot baths, massage.
Use skin care lotions/ointments as directed by Wound Care
Nurse. Keep skin clean & dry.
Keep head of bed at lowest elevation as is medically
possible.
Manage incontinence, use diapers sparingly.
Encourage the patient to use bed rails/ trapeze bar etc
to participate in repositioning/turning.
Monitor nutrition & hydration status. Give diet & fluids
as ordered & monitor intake/output.
Use vigilance to assess patients with casts, hard splints,
back slabs, traction, O2 tubing, masks, neck collar and
support stockings.

Review outcomes of plan and

interventions
Assess skin and pressure ulcer risk each shift

Wound Care SKMC