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Chase Toth

9/18/2017

Wholly/MedSurg

Inpatient Wound Care Objectives

Henry Ford Allegiance Care Link- Wound Care

The Braden Score is very important in assessing patients for skin breakdown or for

measuring how much of a risk a patient may be at for pressure ulcers. A few major categories it

looks at are, the patients: sensory perception (also LOC in order to detect pain), moisture the skin

is exposed to, their activity and mobility (Can they ambulate? Or are they bed-bound?) , nutrition

(Are they taking in adequate nutrition? Or obese?) , and any friction and shearing they could

possibly be exposed to. The higher the number, the better; 19-23 there is no risk, and a score of 9

or less means a high risk for pressure ulcer formation.

There are many interventions Nurses can do to prevent the formations of pressure ulcers.

The first major thing to do is, always assess your patient and check them from head to toe and do

a Braden Risk Assessment. If they have already pre-existing areas that are affected, those places

will be at higher risk. One thing you could do, is get a weight redistribution device that will shift

their weight side to side. If not available, you can float extremities with pillows, like heels and

elbows and turn them left or right, every 2 hours and place a pillow on their back-side. There are

also heel-lift devices available as well. Another important thing to do is, assess for moisture. Are

they incontinent of feces or urine? Obese patients may have moisture underneath breasts/chest

area, panniculus (or pannus), and other areas that are covered by layers of skin. These areas

should be cleaned and appropriate ointments and powders should be applied. Also, reddened
areas or bruised areas on the coccyx/sacrum(buttocks and lower back) area should be padded and

the correct ointments should be used appropriately due to those areas being two of the most

common sites for ulcer formation (Other common sites are: back of the head, shoulders, elbows,

and heels). Another intervention for someone who is possibly: bed-ridden, altered

LOC/disoriented, post-surgical, or elderly or not very mobile/active is performing ROM

activities with them or possibly just trying to get them to move a little or even ambulating or

sitting up just to change their position of their body to get them off of those areas that are prone

to pressure ulcer formation. And lastly, to lower friction and shearing forces, appropriate padding

should be used, lift devices set in place, and less sheets and blankets under the patient as

possible. Lifting devices include: transfer devices like Hoyer lifts, EZ-stand, Hercules beds,

securement devices (like for nasal cannulas, or traches), and also things like Hover Matt, which

inflate under the patient to help them slide over without causing shearing/friction of the patients

skin.

Lastly, important assessments to make for a patient with a wound-vac are: correct order

for correct patient, correct supplies for the correct dressing and wound care for that specific

wound, precise measurement of wounds and picture for Progress Notes, correct suction (usually

125 mmHg and continuous but can vary on wound and orders), you always want to assess

patients pain, is the equipment working, what does the drainage look like, what does the wound

look like, and then always evaluate the patient after your assessment and treatment, this may also

come with patient education of the wound-vac and the dressing, especially before discharge.

Which wounds require this type of treatment with a wound-vac? It works for many wounds of

many types but the patients who seek the most benefit are those with chronic and deep wounds.

It helps increase healing, decrease discomfort, decreases infection risk, and promotes
vasodilation which increases granulation tissue, which in turn decreases the patients stay at the

facility.