The policies and procedures establish clinical and operational standards necessary to support comprehensive inpatient and outpatient wound care services. They are structured to align with Medicare, Medicaid, and other federally funded payer requirements, as well as applicable standards for private insurance payers.
POLICY HEADER
- Document Name: Pressure Injury Assessment, Treatment, and Prevention
- Document Number: ____
- Effective Date: __/__/__ Date of last revision: __/__/__
- Policy Owner: __________________________
- Responsible Department: __________________________
- Approved By: __________________________
PURPOSE
- In-Patient: To identify the process for assessing patient risk for skin breakdown using the [Braden Scale for Predicting Pressure Injury Risk or facility-approved validated risk assessment tool ], identifying other risk factors, developing and implementing appropriate interventions based on the score obtained and risk factors identified, and initiate treatment and management of skin integrity.
- Out-Patient: Nursing assessment of integumentary as indicated for all patients.
POLICY STATEMENTS
All patients will have a nursing assessment, care planning, intervention, and evaluation of potential or actual skin impairment during a hospital admission.
Evaluation of potential or actual skin impairment consists of comprehensive skin assessment and pressure ulcer/injury risk assessment.
Comprehensive Skin Assessment
Upon Admission
- A comprehensive, head‑to‑toe skin assessment will be completed upon admission to an inpatient unit to identify existing skin conditions and support accurate present-on-admission documentation.
- The admission skin assessment should be verified by a second licensed nurse (i.e., 4 eyes in 4 hours) to support accurate identification of skin conditions present on admission. If second‑nurse verification is not feasible, the assessment may be completed by a single licensed nurse, and the circumstances will be documented in the electronic health record (EHR).
- Admission skin assessments will include inspection of all skin surfaces, including areas under and around medical devices if able to be removed.
After Admission
- Routine comprehensive skin assessments will be performed based on care setting, patient acuity, risk, and organizational standards as follows:
- Acute care, step-down, geriatric, and behavioral health units: At least once per shift, with no more than 12 hours between assessments unless clinically justified.
- Emergency Department holds: At least once per shift or not to exceed 12 hours between assessments.
- Intensive care/ critical care units: At least once per shift, with no more than 12 hours between assessments. Patients identified as high risk may require more frequent targeted skin inspections based on clinical judgment.
- Long‑term care settings: At least weekly for a comprehensive assessment, with increased frequency for patients identified as high risk.
- Skin assessment frequency and prevention strategies will be individualized based on patient-specific risk factors, clinical presentation, and professional nursing judgment. Frequency may be increased at any time in response to changes in patient condition, mobility, perfusion, nutrition, device use, or other indicators of elevated risk to support patient safety.
- In addition to scheduled comprehensive assessments, targeted skin inspections will be conducted during routine patient care activities, with particular attention to vulnerable anatomical areas (e.g., looking at coccyx/sacrum when turning or cleaning a patient) and skin beneath medical devices (if able to be removed). These focused inspections support early identification of skin compromise and do not replace scheduled comprehensive assessments.
All Care Settings
In all healthcare settings, skin assessments will also be performed:
- Upon admission and upon discharge
- Upon transfer to another unit or level of care
- With any significant change in patient condition, mobility, or hemodynamic status
- Following procedures associated with prolonged immobility
- With initiation, prolonged use, or discontinuation of medical devices (e.g., oxygen delivery devices, restraints, splints, casts, lines, or tubes)
All findings, including the presence or absence of pressure injuries, will be documented in the EHR using standardized terminology and staging consistent with current national guidelines.
Pressure Ulcer/Injury Risk Assessment
- Pressure ulcer/injury risk assessments will be completed with a validated risk assessment tool and documented in the EHR:
- Upon admission
- At least daily for inpatients, at a time determined by unit‑specific workflow
- With any significant change in patient condition
- Upon transfer to a different unit or level of care
- As clinically indicated
- A discharge assessment may be performed to support care transitions and documentation of skin status.
- Risk assessment findings shall be used to guide individualized, evidence‑based prevention strategies.
Validated Risk Assessment Tools
- The organization will utilize approved, validated tools to assess pressure injury risk.
- Validated and facility-approved tools include:
- [Braden Scale for adult patients]
- [Braden Q Scale for pediatric patients under eight (8) years of age]
- Newborns and infants will be assessed using an age-appropriate validated, organization-approved pediatric tool, particularly when:
- RN assessment identifies potential for skin alteration, and/or
- Medical devices or therapies place the patient at risk for pressure‑related skin injury
- Risk reassessments will occur according to the triggers outlined above and more frequently when warranted by patient condition or clinical judgment.
Additional Risk Factors
- In addition to validated risk assessment tools, nurses will identify and document relevant patient-specific risk factors supported by current evidence. These may include, but are not limited to:
- Advanced age
- Sustained hypotension/use of pressors
- History of radiation therapy to high‑risk anatomical areas
- Frequent or prolonged off‑unit travel for diagnostic or procedural care
- Severe anemia
- Delayed surgical intervention due to medical instability
- These additional risk factors identified during skin assessment will be documented in the EHR and incorporated into care planning.
Interventions
- Patients identified as at risk will receive timely, evidence-based prevention interventions.
- Interventions will be guided by:
- Validated risk assessment scores and subscale findings
- Patient-specific risk factors
- Clinical nursing judgment
- Interventions are outlined in Table 1 below and will be incorporated into the individualized plan of care.
DEFINITIONS
Pressure Injury
A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open injury and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition and hydration status, perfusion, co-morbidities and condition of the soft tissue.
Pressure Ulcers/Injuries stages and additional definitions as per the National Pressure Ulcer Advisory Panel (NPIAP) are listed below [14]:
1. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
2. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
3. Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
4. Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
5. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
6. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
Additional pressure injury definitions
1. Medical Device Related Pressure Injury:
This describes an etiology.
Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes.
a. The resultant pressure injury generally conforms to the pattern or shape of the device.
b. The injury should be staged using the staging system.
2. Mucosal Membrane Pressure Injury: Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be staged.
SCOPE
Who
RN responsible for care of the patient.
Where
[Name of the hospital/ location of the program]
PROCEDURES
In-Patient Protocol
Table 1. Pressure Ulcer/Injury Prevention Policy Summary
* Group 1 support surfaces: include mattresses, pressure pads, and powered pressure reducing mattress overlays (foam, air, water, or gel) (HCPCS E0181-E0189, E0196-E0199, and A4640). Group 2 support surfaces: include powered air flotation beds, powered pressure reducing air mattresses, and non-powered advanced pressure reducing mattresses (HCPCS E0193, E0277, E0371-E0373). Group 3 support surfaces: are complete bed systems, known as air-fluidized beds, which use the circulation of filtered air through silicone beads (HCPCS E0194) [7][9][11][15]
| Assessment | Interventions | Documentation |
| Total Braden/Braden Q Score < 18 | - Pressure redistribution support surface that meets minimum of CMS Group 1 support surface*. Use Algorithms 1A and 1B to determine need for Group 2 or 3 support surface*.
- Limit layers under patient to 1 only in addition to bed sheet
- Chair cushion
- Turn and reposition if Braden Scale shows:
- Sensory Perception subset score is 2 or less or
- Mobility subset score is 2 or less.
- Note: Patient may be independent, need cueing or assistance in turning/repositioning
| Complete Braden Scale - Upon Admission and discharge
- Daily by [enter desired target time]
- At transfer between levels of care, sending and receiving unit (includes post-op).
- Change in condition/unit.
- Patient’s primary RN is responsible for determining the frequency of repositioning and revising the plan of care
|
Mobility/Activity/Sensory Perception Braden/Braden Q Subscore < 2 | - Pressure redistribution support surface that meets minimum of CMS Group 1 support surface*. Use Algorithms 1A and 1B to determine need for Group 2 or 3 support surface*.
- Chair cushion
- Turn and reposition
- If Mobility subset score on Braden Scale Braden 2 or less.
- Note: Patient may need assistance in turning/repositioning
- Elevate heels off bed using pillow under calf OR offloading boots
| - Document position changes and all appropriate interventions
- Document all interventions on the Plan of Care in the EHR.
|
Moisture Risk Braden/Braden Q Subscore < 3 | - Cleanse using agents designed to be skin friendly and approved by facility
- Use moisturizer PRN
- Incontinence underpads (1 only)
- No diapers
- Patients who are ambulatory and wish to use their own diapers may do so, document in chart.
- Moisture barrier product at least daily and PRN
- Use fecal containment pouch PRN or fecal management system.
- Pouch surgical drains with pouches/ostomy appliances PRN.
- If no improvement in 3 days or if skin declines
- Start moisture barrier product 3 x day and PRN
- If candidiasis present:
- Start topical antifungal therapy
- Use condom catheter, retracted penis pouch, or per guidelines for use of external female collection device
| - Document all interventions on Plan of Care in the EHR.
|
Friction/Shear Risk Braden/Braden Q Subscore < 2 | - Head of bed elevated < 30-45 degrees (if patient can tolerate and not contraindicated)
- Use lotion to remove adhesives
- Multilayered soft silicone foam dressing if indicated to elbows/heels/sacrum
- Change every 3 days and PRN
- Elevate heels off bed using pillow under calf OR offloading boots
| - Document all interventions on Plan of Care in the EHR.
|
| Skin Risk Assessment of Very Poor and Probably Inadequate Intake | - Initiate nutrition consult if registered dietitian has not seen patient
| - Document on Plan of Care in the EHR.
|
TREATMENT
General Wound Care Interventions
- Initiate interventions to manage factors contributing to pressure related skin breakdown. See TABLE 1 above.
- Relieve pressure to compromised skin area.
- If not already in place, notify the provider to obtain an order to initiate the ["Skin Protocol Orders"] in accordance with facility policy. This order allows the nurse to place protocol orders from the ["Patient Skin Products Order Set"].
- Assess for pain. Consult with provider related to appropriate pain management plan.
- With open wounds, prior to dressing change, clean wound with normal saline or wound cleanser.
- Mark date, time, and care provider initials on all dressings.
- Refer to TABLE 2 below for treatments specific to each skin alteration.
- Refer to TABLE 3A, 3B and 3C to determine if skin product requires an order and where to obtain necessary item [update TABLE 3 according to facility/program].
- Refer to ALGORITHMS 1A and 1B for pressure redistribution support surface bed algorithm
- Notify provider of skin alteration and initiation of protocol.
- For specialized patient populations, apply prophylactic protective dressing [e.g. Optiview] over areas of risk. The specialized populations are:
- Patient’s ONLY able to tolerate a high Fowler’s Position AND already on an [Isogel or Accumax] mattress
- Extreme bony prominences (e.g., severe cachexia, kyphosis) on torso
- Patients on BiPap and unable to reposition
- Patients with profound protein calorie-malnutrition
- Critical care patients going to operating room or a diagnostic procedure
- Upon recommendation of Provider and/or wound consult
Table 2. Skin Impairment Interventions
| Dressings / Topicals Assessment | Interventions | Documentation |
| Yeast / Fungal Rash | - Topical antifungal therapy per provider order
| - Obtain MD/APRN/PA order for initiation of [skin care protocol].
- Document in wound assessment and on Plan of Care in the EHR.
- Re-eval progress every 3 days & PRN
|
| Stage 1 | - All pressure redistribution interventions
- Pressure redistribution support surface for bed. See Algorithms 1A and 1B.
- Static air chair cushion
- Elevate heels off bed using pillow under calf OR offloading boot
- Protect skin from moisture/incontinence
- Turn/reposition as identified on Plan of Care
- Apply multilayer foam dressing to affected site
- Positioning/turning to reduce pressure on affected areas
- Nutrition consult if:
- Numerous Stage 1s
- Large Stage 1
- If poor nutritional intake.
| - Document wound assessment and measurements (in centimeters) wound assessment in the EHR:
- Upon discovery/admission
- With each change in patient status
- On [insert day of the week in accordance with facility protocol]
- Post-op
- Upon discharge.
- Document treatment plan and dressing change frequency/date on Plan of Care in the EHR.
|
| Stage 2 | - All pressure redistribution interventions as outlined in Stage 1.
- Apply multilayer foam dressing to affected site.
| |
Stage 3 Stage 4 | - All pressure redistribution interventions as outlined in Stage 1.
- Nutrition consult.
- Wet to moist normal saline gauze dressing twice a day until Wound Team/MD/ APRN/PA determines wound management plan.
- Consult [Wound Team - insert facility process to place order wound consult]
| - Document wound assessment and measurements (in centimeters) wound assessment in the EHR:
- Upon discovery/admission
- With each change in patient status
- On [insert day of the week in accordance with facility protocol]
- Post-op
- Upon discharge.
- Document treatment and dressing change frequency/date plan on Plan of Care in the EHR.
|
| Unstageable/Deep Tissue Injury (DTI) | - All pressure redistribution interventions as outlined in Stage 1.
- Nutrition consult.
- For deep tissue injury without drainage, use a protective foam.
- For unstageable wounds or deep tissue injury with drainage, wet to moist normal saline gauze dressing twice a day until Wound Team/MD/ APRN/PA determines wound management plan.
- Consult [Wound Team - insert facility process to place order wound consult]
- If on heels, keep eschar dry until assessed by painting areas daily with povidone-iodine
| - Document wound assessment and measurements (in centimeters) wound assessment in the EHR:
- Upon discovery/admission
- With each change in patient status
- On [insert day of the week in accordance with facility protocol]
- Post-op
- Upon discharge.
- Document treatment and dressing change frequency/date plan on Plan of Care in the EHR.
|
Table 3A. Approved Medication Items from Pharmacy Requiring a Provider Order
[ customize according to facility formulary and policy requirements ]
| Indication | Product | Suggested Dosage |
| Severely denuded skin associated with incontinence associated dermatitis | Barrier products (sprays, ointments, creams, pastes) | Apply to affected areas up to four times a day and prn after incontinence episode per product instructions |
| Pruritus/ renal patients | Camphor/Menthol | Apply to affected areas twice a day and prn |
| Apply to dry, clean wounds | Amorphous hydrogel | Apply daily and cover with gauze dressing. Initiate wound consult |
| Superficial skin fungal infections | Topical antifungal agents (ointments, creams) | Apply to affected area twice a day |
| Skin tears or minor abrasions | Topical antibiotics | Apply to open area and cover with suitable dressing |
Table 3B. Skin products that may require a provider order
[ customize according to facility formulary and policy requirements ]
| Indication | Product | Suggested Use |
| Prevention of skin alterations associated with incontinence | Skin protectants/ moisture barriers | Apply twice a day and after incontinent episodes |
| Skin tears | Skin sealants | Apply at time of superficial skin injury; may repeat as needed if area reopens |
| Dry skin | Moisturizers | Apply to affected areas twice a day |
Algorithms 1A and 1B. Selection of Hospital Bed and Pressure Redistribution Support Surface
Algorithm 1A. Hospital Bed and Pressure Redistribution Support Surface
Algorithm 1B. Hospital Bed and Pressure Redistribution Support Surface
Special Situations – Bariatric or Critical Care Pulmonary or Tall Patient Bed Extender to Foot of Bed
Documentation
1. Structured validated risk assessment: Braden Scale/Braden Q for Predicting Pressure Sore Risk and other identified clinical risk factors. Complete upon:
- Upon admission
- Discharge
- At least daily for inpatients, at a time determined by unit‑specific workflow
- With any significant change in patient condition
- Upon transfer to a different unit or level of care
- As clinically indicated
- Exception: On admission and then weekly for patients identified as low risk on admission.
2. Skin Assessment: document a skin assessment whenever a PU/PI risk assessment is documented and at these intervals after admission:
- Acute care, step-down, geriatric, and behavioral health units: At least once per shift, with no more than 12 hours between assessments unless clinically justified.
- Emergency Department holds: At least once per shift or not to exceed 12 hours between assessments.
- Intensive care/ critical care units: At least once per shift, with no more than 12 hours between assessments. Patients identified as high risk may require more frequent targeted skin inspections based on clinical judgment.
- Long‑term care settings: At least weekly for a comprehensive assessment, with increased frequency for patients identified as high risk.
- All settings: in all healthcare settings, skin and PU/PI risk assessments are also performed:
- Upon admission and upon discharge
- Upon transfer to another unit or level of care
- With any significant change in patient condition, mobility, or hemodynamic status
- Following procedures associated with prolonged immobility
- With initiation, prolonged use, or discontinuation of medical devices (e.g., oxygen delivery devices, restraints, splints, casts, lines, or tubes)
3. Wound Assessment: Complete:
- Upon identification of pressure injury/skin breakdown
- Once in every 24 hours with dressing change
- Exception: if dressing change interval is greater than every 24 hours, document at time of each dressing change.
4. Document skin assessment in RN Skin Assessment in the EHR.
5. All wounds are re-measured during the patient’s dressing change.
6. Emergency Department: Assessment for acuity Level I – III, documentation only of integumentary abnormalities.
7. Outpatient: Integumentary assessment with documentation of abnormalities.
APPENDIX
Appendix A: Organization-Approved Pressure Injury Risk Assessment Tool for Adults
[Facility to insert validated risk assessment tool utilized by the organization (e.g., Braden Scale) in the Appendix of the Policy and Procedure.]
Appendix B: Pediatric Pressure Injury Risk Assessment Tool
[Facility to insert organization-approved pediatric risk assessment tool (e.g., Braden Q Scale).]
Braden Scale – Summary Description (For Reference)
Many healthcare organizations utilize the Braden Scale as a validated tool to assess risk for pressure injury development.
- In the United States, the most used structured risk assessment tool for people over 8 years of age is the “Braden Scale for Predicting Pressure Sore Risk ” tool. [16][17] A specific version for home care exists: "Braden Scale for Predicting Pressure Sore Risk in Home Care".
- For children under eight (8) years of age, the Braden Q Scale is a validated pediatric adaptation of the adult Braden Scale.[18]
Note: The Braden Scale is a copyrighted assessment instrument. Facilities are responsible for ensuring appropriate licensing prior to reproducing or distributing the full scale.
The Braden Scale evaluates patient risk across six domains commonly associated with pressure injury development:
- Sensory perception
- Skin moisture exposure
- Physical activity level
- Mobility
- Nutritional status
- Friction and shear exposure
Each domain is assigned a numerical value reflecting the patient’s current condition. The cumulative score is used to stratify patients into risk categories ranging from low to high risk. Lower total scores are associated with greater pressure injury risk.
