Skin Safety & Prevention of Pressure Ulcers

A skin assessment should be performed for an inpatient based on a standardized skin and/or risk assessment tool such as the Braden scale. A full head to toe skin assessment should be carried out on every patient admitted into an acute care setting it in 6 hours of admission with a reassessment performed every 8-24 hours. A skin care policy and physicians consult should be implemented for skin care orders if a patient is found to be at risk of developing a pressure ulcer or if one already exist. A skin care policy (per facility) should consist of nursing interventions that will decrease or exclude friction, shearing, pressure, moisture, and adding maintenance of adequate nutrition and hydration (Institute of Clinical Systems Improvement, 2007).

All skin/risk assessments, their findings, and the initiation of a skin care policy plan should be documented utilizing a consistent documentation format (per facility). Skin/risk assessments, inspection findings, of the developments of a pressure ulcer should be communicated consistently along with any changes that may occur in the patients skin condition as soon as possible (Institute for Clinical Systems Improvement, 2007).

Reference:

Institute for Clinical Systems Improvement (2007). Skin safety protocol: Risk assessment and prevention of pressure ulcers. Retrieved from http://www.njha.com/qualityinstitute/pdf/226200833420PM63.pdf