Impaired mobility, ALOC, and decreased sensation
Turn Truly Every 1- 2 hours
Pressure Sores
Risk Factors
Trudy is critically-ill in the intensive care unit. Let's see what makes her at risk for pressure ulcers and what you should do about it as a nurse.
Shearing and friction
Use a draw sheet
Malnutrition
TPN, Tube Feedings. and oral supplements when ready. Vitamin C, Zinc, Carbs, and protein.
Dehydration
Simple! Keep hydrated
Fecal/Urinary Incontinence
Good pericare. May need a foley or a rectal tube to keep skin clean.
Advanced age
She is lucky she is young
Chronic Conditions
Lucky she is not DIABETIC
Casts, restraints, and tracton 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.
Treatments
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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 is 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.