Braden
Responds to verbal commands, but cannot always communicate discomfort or need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort
Slightly Limited (Sensory)
The amount of picture(s) that should be taken of the suspected PI/skin abnormality
2: One up close and one further back to show patient position
Performed/documented on admission, transfer into unit and upon return from procedure/dialysis
2 RN Skin Check
ChristianaCare specific reference document
Skin Integrity CMG
Tool used to identify patients at risk for pressure injuries
Braden
Skin is often, but not always, moist. Linens must be changed at least once a shift.
Very Moist (Moisture)
Correct label of picture taken
Date and Anatomical Location (i.e. 2024-09-04 Sacrum)
Q8h and PRN
Frequency of skin assessments unless more frequent required related to Braden score
Team of skin and wound specialty trained RN's
WOC Team
Adhesive Foam for PI prevention
Mepilex
Eats over half of most meals. On a tube feeding or TPN regimen which probably meets most of nutritional needs.
Measuring tape, patient label, no glare, good quality/visible picture
Requirements for camera capture wound picture
Using hand to ensure posterior pelvis is elevated off the bed
Hand Check Procedure
Bundle of evidenced based items to implement for patients at risk for pressure injuries
HAPI Perfect Care Bundle
Turn frequency / Weight Shifting Frequency
q2h in bed, q1h in the chair, q15 min in chair if pt can reposition self
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.
Problem (Friction and Sheer)
Folder that pictures are saved to
Skin/Wound Folder
Q4 & PRN
Skin assessment frequency with sensory Perception Score of 2 on the Braden
Recommendations for wound treatment
WOC Consult (Wound evaluation)
Best device to use when turning your patients
Wedge
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment which limits the ability to feel pain or discomfort over half of body.
Very Limited (Sensory Perception)
Any abnormality on the posterior pelvis and/or any suspected PI's
When to use camera capture
Q2 & PRN
Skin assessment frequency when sensory Perception Score is 1 on the Braden
Megan Campana
Our unit WTA (Wound Treatment Associate)
Device used for heels for patients that cannot lift legs independently and are at risk for heel ulcers
TrueVue Heel Protector (Located in hallway storage closet)