Pressure Sores
Risk Factors
| Risk Factor | Intervention |
|---|---|
| Impaired Mobility, ALOC, and ↓ Sensation | Turn every 1 to 2 hours |
| Shearing and Friction | Use a draw sheet |
| Malnutrition | TPN, tube feedings, and oral supplements when ready. vitamin C, Zinc, Carbs, and Protein |
| Dehydration | Keep Hydrated |
| Fecal/ Urinary Incontinence | Good pericare. May need a foley or a rectal tube to keep skin clean. |
| Advanced Age | Trudy is lucky she is young |
| Chronic Conditions | Trudy is lucky she is not diabetic. But if diabetic, keep blood sugar under control. |
| Casts, restraints, and traction devices. | Assess skin under these devices. |
Risk Assessment Braden Scale
- Sensory Perception
- Moisture
- Mobility
- Nutrition
- Friction and Shear
- Very High Risk: Total Score 9 or less
- High Risk: Total Score 10-12
- Moderate Risk: Total Score 13-14
- Mild Risk: Total Score 15-18
- No Risk: Total Score 19-23
- Intact skin with nonblanchable redness
- Loss of dermis
- Red-pink wound bed
- Full-thickness tissue loss with subcutaneous fat visible.
- Full-thickness tissue loss with bone, tendon, or mucleexposed.
- Undermining or tunneling may be present.
Nursing Priorities
- Assess skin especially over bony prominences
- Turn every 1 to 2 hours
- Pressure relieving mattresses
- Avoid shearing/friction to skin by using lift sheets.
- Heels off bed
- HOB elevated < 30 degrees if possible
- Use mild soap to cleanse skin.
- Moisturize skin and apply barriers creams
- Nutritional supplements and hydration
- Minimize skin exposure to fecal, urinary, or any drainage.