Risks for Skin Failure
This condition is when the body doesn't receive enough protein or calories
What is: Malnutrition
A patient has potential for skin failure, what are two key interventions nursing can implement to prevent breakdown
What is: More frequent skin assessments and repositioning
Based on the Algorithm, name 4 factors that qualify this patient for skin failure
What are...
Use of 2+ vasopressors/inotropes
MTP (>10 units in 24 hours)
Atypical location of skin injury present
New diagnosis of renal failure requiring HD/CRRT
Part of the Pressure Injury Prevention Bundle, this type of mattress should be considered for patients with multiple co-morbidities or perfusion challenges.
Low Air Loss mattress/ICU bed, or mattress overlay
This patient required ongoing transfusions and received more than 10 units of blood products in 24 hours, meeting this major criterion for skin failure.
What is MTP?
High doses or prolonged use of these medications, which support blood pressure, can reduce skin perfusion and increase the risk for skin failure
What are vasopressors
This standardized nursing bundle guides prevention and documentation efforts for skin integrity in high-risk patients.
Pressure Injury Prevention Bundle
Additional co-morbidities that put this patient at increased risk for skin breakdown, list them
These commonly used medical supplies should be repositioned, stabilized, or padded to reduce friction and shear.
What are tubes and lines (or invasive devices)
The use of two vasopressors, such as norepinephrine and vasopressin identify this critical physiologic state that compromises skin perfusion.
What is shock
This condition, known for decreased tissue oxygenation due to shock, sepsis, or hypoperfusion, increases risk for skin injury
What is: Tissue hypoxia (poor perfusion)
Even when mobility is limited, this assistive device can be inflated briefly to reduce pressure under the patient.
What is: Hover mat- inflated for 5-10 minutes
A patient on CRRT has this type of organ dysfunction, which contributes to metabolic imbalance and impaired skin integrity
What is: Renal Failure
This principle of minimizing barriers between patient and support surface helps maximize pressure redistribution.
What is minimizing layers under the patient
Extended time in this hospital location increases the patient’s risk for immobility-related pressure injuries.
What is Operating room
Use of anticoagulants like Eliquis increases bruising and hematoma risk, making what large organ system vulnerable to injury.
What is: The skin
A very low Braden score, such as 6, indicates this overall level of risk.
Severe risk for pressure injury
This patient was unable to tolerate turns. What opportunities exist in the ICU setting to support offloading when turns are not tolerated?
Reducing this bed position angle minimizes shear forces on the sacrum
What is lowering the head of bed to less than 30 degrees
This device, used to stabilize pelvic fractures, can exert prolonged localized pressure if not frequently reassessed.
What is a pelvic binder
When a patient develops atypical skin changes such as mottling and pulse loss in the hands, these are early indicators of this phenomenon related to poor perfusion
ischemic injury or skin failure
What is: Traction
This chronic condition impairs microvascular circulation and delays wound healing, increasing risk for skin breakdown.
Diabetes
When a patient’s Braden sub-score is this number or lower in any category, nurses should implement targeted interventions.
What is ≤2
This factor from the trauma itself can worsen perfusion and limit turning options due to instability
What are multiple fractures or polytrauma