PURPOSE
In-Patient: To identify the process for assessing patient risk for skin breakdown using the Braden Scale for Predicting Pressure Injury Risk, 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 impairment.
Out-Patient: Review of systems to be performed by nursing assessment of integumentary as indicated for all patients.
POLICY STATEMENTS
- All patients will have a nursing assessment, PU/PI risk assessment. comprehensive skin assessment. care planning, intervention, and evaluation of potential or actual skin impairment during a hospital admission.
- Upon admission:
- Skin assessment is done by 2 RN authentication with admission to an inpatient unit. If 2 RN authentication is not possible due to special circumstances, the reason for opting out must be documented in the EHR.
- Risk assessment should be performed upon admission (refer to item 2)
- After admission: Routine skin assessment and PU/PI risk assessment after admission occurs as follows:
- Acute care settings at least once every 24 hours [update this section according to facility policy for individual units].
- Emergency Department Hold at a minimum of every 8 hours.
- Critical care at a minimum of every 8 hour shift.
- Operating room at least every 4 hours for longer operations (include time in the holding and recovery room when assessing time) and upon discharge to the recovery room.
- Long-term care: weekly for first 4 weeks after admission, then at least monthly.
- All settings: in all healthcare settings, skin and PU/PI risk assessments are also performed:
- Significant change in condition
- Upon discharge
- PU/PI Risk Assessment with a validated scale: Braden Scale [update this section according to facility’s validated PU/PI risk assessment scales such as Braden Scale, Norton].
- The Braden Scale will be used for assessing patient risk for pressure injuries upon admission, discharge, transfer to a different level of care, change in condition, and every day by [enter desired target time].
- The Braden Q scale will be used for pediatric patients under the age of 8 and newborns found to have a potential for skin alteration based on the RN assessment or whose care requires the use of a device that places the newborn at risk for a skin alteration related to pressure.
- Additional Risk Assessment
- In addition to the Braden Scale, the following additional risk factors substantiated in the literature should be documented in the EHR:
- Age greater than 60
- Mean arterial pressure less than 65,
- History of radiation to pelvis,
- Off-unit for two or more procedures in a 24-hour period,
- Severe anemia (H&H less than 7.5/21.0),
- Delayed orthopedic surgical procedure due to a medical condition.
- Other risk factors not included in this list must be identified during the 2 RN skin authentication process.
- Interventions: Staff will utilize appropriate interventions identified on TABLE #1 below. The interventions chosen will be determined by the Braden/Braden Q subset score assigned to the patient and/or clinical nursing judgment.
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.
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]
PROCEDURE
In-Patient Protocol:
TABLE #1. [name of the hospital/ program ] HAPI Prevention Policy Summary
| Assessment | Interventions | Documentation |
| Total Braden/Braden Q Score < 18 | - Standard pressure redistribution bed [e.g Isoflex or Accumax];
- 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 | - Standard pressure redistribution bed (e.g. Isoflex or Accumax)
- Use approved mattress per patient setting [update this section according to facility bed protocol]
- 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 Electronic Health Record.
|
Moisture Risk Braden/Braden Q Subscore < 3 | - Cleanse using agents designed to be skin friendly and approved by facility
- Use moisturizer PRN
- Incontinence underpads
- No diapers
- Patients who are ambulatory and wish to use their own diapers may do so, document in chart.
- Moisture barrier cream 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 barrier paste (e.g. Remedy Clinical Zinc Oxide Paste or Critic Aid) 3x day and PRN
- If candidiasis present:
- Start miconazole 2% based-cream twice a day for 7 days
- If above ineffective, add a non-adhering, petrolatum-impregnated gauze dressing that contains 3% bismuth tribromophenate applied over paste 4 times a day and PRN
- 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 Electronic Health Record.
|
Friction/Shear Risk Braden/Braden Q Subscore < 2 | - HOB elevated < 30-45 degrees (if patient can tolerate and not contraindicated)
- Use lotion to remove adhesives
- Hydrocolloid or foam dressing if indicated to elbows/heels
- 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 Electronic Health Record.
|
| Skin Risk Assessment of Very Poor and Probably Inadequate Intake | - Initiate nutrition consult if RD has not seen patient
| - Document on Plan of Care in the Electronic Health Record.
|
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.
- Contact Provider to obtain order for ["Initiate Skin Protocol Orders"]. 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.
- 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 #3 to determine if skin product requires an order and campus location to obtain necessary item [update TABLE #3 according to facility/program].
- Refer to TABLE #4 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 or Hydrocolloid] over areas of risk. The specialized populations are:
- Patients with liquid stool unable to be contained with an external pouch AND contraindications to an internally placed fecal management system
- Patient’s ONLY able to tolerate a high Fowler’s Position AND already on an [Isogel or Accumax] mattress
- Extreme bony prominences (examples – 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 | - Miconazole 2% based-cream twice per day x 7 days
| - Obtain MD/APRN/PA order for initiation of [skin care protocol].
- Document in wound assessment and on Plan of Care in the Electronic Health Record (EHR).
- Re-eval progress every 3 days & PRN
|
| Stage 1 | - All pressure reduction interventions
- [e.g. Isoflex or Accumax] mattress for bed
- 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 hydrocolloid or 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 Electronic Health Record:
- Upon discovery/admission
- With each change in patient status
- On [insert name of day per facility protocol]
- Post-op
- Upon discharge.
- Document treatment plan and dressing change frequency/date on Plan of Care in the Electronic Health Record.
|
| Stage 2 | - Same as for Stage 1.
- Apply hydrocolloid or foam dressing to affected site.
| |
Stage 3 Stage 4 | - All pressure reduction interventions
- Initiate pressure redistribution per facility bed algorithm
- Static air wheelchair 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
- 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 Electronic Health Record:
- Upon discovery/admission
- With each change in patient status
- On [insert name of day per facility protocol]
- Post-op
- Upon discharge.
- Document treatment and dressing change frequency/date plan on Plan of Care in the Electronic Health Record.
|
| Unstageable/Deep Tissue Injury (DTI) | - All pressure reduction interventions
- Initiate pressure redistribution per facility bed algorithm
- Static air wheelchair 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
- 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 Electronic Health Record:
- Upon discovery/admission
- With each change in patient status
- On [insert name of day per facility protocol]
- Post-op
- Upon discharge.
- Document treatment and dressing change frequency/date plan on Plan of Care in the Electronic Health Record.
|
Table # 3. Approved Medication Items from Pharmacy Requiring a Provider order:
| Product | Indication | Suggested Dosage |
| Calazime Skin Protectant Paste | Severely denuded skin associated with incontinence associated dermatitis | Apply to affected areas four times a day and prn after incontinence episode |
| Camphor/Menthol (Sarna) | Pruritus/ renal patients | Apply to affected areas twice a day and prn |
| Amorphous hydrogel | Apply to dry, clean wounds | Apply daily and cover with gauze dressing. Initiate wound consult |
| Saliva substitute | Dry mouth | Two sprays into mouth every two hours prn |
| Dimethicone cream | Dry skin | Apply twice a day |
| 2% Miconazole | Superficial skin fungal infections | Apply to affected area twice a day |
Approved Products Available from Storeroom requiring a Provider order:
| Product | Indication | Suggested Use |
| Zinc Oxide Paste Skin Protectant | Prevention of skin alterations associated with incontinence | Apply twice a day and after incontinent episodes |
| Cyanoacrylate | Skin tears | Apply at time of superficial skin injury; may repeat as needed if area reopens |
| Bacitracin-zinc ointment | Skin tears or minor abrasions. [Insert facility process NOTE: This is a Pharmacy item distributed by the storeroom ] | Apply to open area and cover with suitable dressing |
The following are available to nursing staff from storeroom without need for Provider order:
| Stomahesive Paste/Powder | Adhesive for ostomy wafer | Apply to wafer, allow to “set” for one minute before applying to skin |
| Smoothe & Cool Moisturizing Body Lotion | Dry skin | Apply to affected areas twice a day |
Disposable Washcloths Impregnated with Cleansing Body Foam or Lotion | Bathing and incontinence care | Daily and prn |
| Unscented Odor Eliminator | Odor eliminator | 2 sprays as needed to reduce ambient odor |
| No-Sting Alcohol Free Protective Barrier Wipe | Skin barrier to improve tape and dressing adhesive adherence | Apply to skin and allow to dry before applying tape or dressing adhesive |
| Hair Shampoo | Hair wash | Apply to hair wash and rinse |
| No Rinse Shampoo and Body Wash | No Rinse Hair Shampoo | Apply to hair and allow to dry |
Table #4
Hospital Bed Algorithm
Hospital Bed Algorithm
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:
- Admission
- Discharge
- Transfer to a different level of care
- Change in condition
- Daily by [insert time per facility protocol].
- 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 settings at least once every 24 hours [update this section according to facility policy for individual units].
- ED Hold at a minimum of every 8 hours.
- Critical care at a minimum of every 8 hour shift.
- Operating room at least every 4 hours for longer operations (include time in the holding and recovery room when assessing time) and upon discharge to the recovery room.
- Long-term care: weekly for first 4 weeks after admission, then at least monthly.
- All settings: in all healthcare settings, skin and PU/PI risk assessments are also performed:
- Significant change in condition
- Upon discharge
- If dressings are used as a prevention intervention, document skin condition under the dressing daily.
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 (i.e., hydrocolloid every 3-5 days).
4. Document skin assessment in RN Skin Assessment in the EHR.
5. All wounds are re-measured during the patient’s skin assessment every [insert day of week per facility protocol].
- Exception: Patients whose negative pressure wound therapy dressings are not scheduled on [insert day of week per facility protocol].
6. Emergency Department: Assessment for acuity Level I – III, documentation only of integumentary abnormalities.
7. Outpatient: Integumentary assessment with documentation of abnormalities.
CROSS REFERENCED DOCUMENTS
Braden Scale (Adults and children older than age 8)
| Indicator | Scoring Definitions |
Sensory perception (Ability to experience and communicate pain or discomfort) | 1. Completely limited (Unresponsive—does not moan, flinch or grasp to painful stimuli due to diminished LOC or sedation, OR limited ability to feel pain over most of body surface) 2. Very limited (Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has sensory impairment that limits ability to feel pain of discomfort over half of body) 3. Slightly limited (Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has sensory impairment that limits ability to feel pain of discomfort in 1-2 extremities) 4. No impairment |
Moisture (Degree to which skin is exposed to moisture) | 1. Constantly moist (Skin constantly moist from perspiration, urine, drainage, etc. Moistness apparent every time patient moved or turned) 2. Very moist (Skin is often, but not always moist. Linen must be changed at least once a shift) 3. Occasionally moist (Linen change required approximately once a day) 4. Rarely moist (Skin usually dry. Linen changed at routine intervals) |
Activity (Degree of physical activity) | 1. Bedfast (confined to bed) 2. Chairfast (Severely limited or nonexistent walking ability. Cannot bear own weight and/or must be assisted to chair) 3. Walks occasionally (Spends majority of day in bed or chair. Walks occasionally but for very short distances with or without assistance.) 4. Walks frequently (Walks outside of room at least twice daily and inside room at least once every 2 hours while awake. |
| Mobility | 1. Completely immobile (Does not make even slight changes in body or extremity position without assistance) 2. Very limited (Makes occasional slight changes in body or extremity position, but unable to completely turn self independently) 3. Slightly limited (Makes frequent but slight changes in body or extremity position independently) 4. No limitations |
Nutrition (Usual food intake pattern) | 1. Very poor (Never eats a complete meal. Rarely eats more than one third of any food offered. Protein intake only 2 servings meat or dairy per day. Takes fluids poorly. Does not take dietary supplement, OR is NPO and/or on clear liquids or IVs for more than 5 days) 2. Inadequate (Rarely eats a complete meal and usually eats about half of food offered. Protein includes 3 servings of meat or dairy products per day, will occasionally take a nutritional supplement. OR, receives less than optimal amount of liquid diet or tube feedings) 3. Adequate (Eats over half of most meals. Eats 4 servings of protein each day. Occasionally refuses a meal but will take a nutritional supplement. OR, is on a tube feeding or TPN regimen that meets most of nutritional needs) 4. Excellent (Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of protein. Occasionally eats between meals – does not need supplements) |
Friction (Occurs when skin moves against support surfaces) | 1. Problem (requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets impossible. Frequently slides down in bed or chair requiring repositioning with maximum assistance) 2. Potential problem (Moves feebly or requires minimum assistance. Skin slides against sheets, chair, restraints or other devices. Maintains good relative position in chair or bed most of the time) 3. No apparent problem (Moves in bed and chair independently. Maintains good position at all times.) |
Braden Q Scale (Children 8 years of age and younger)
| Indicator | Scoring Definitions |
| Mobility | 1. Completely immobile (Does not make even slight changes in body or extremity positions without assistance) 2. Very limited (Makes occasional slight changes in body or extremity position, but unable to completely turn self independently) 3. Slightly limited (Makes frequent but slight changes in body or extremity position independently) 4. No limitations |
Activity (Degree of physical activity) | 1. Bedfast (Confined to bed) 2. Chairfast (Severely limited or nonexistent walking ability. Non-weightbearing and /or must be assisted to chair) 3. Walks occasionally (Spends majority of day in bed or chair. Walks occasionally but for very short distances with or without assistance.) 4. All patients too young to ambulate OR Walks frequently (Walks outside of room at least twice daily and inside room at least once every 2 hours while awake. |
Sensory perception (Ability to experience and communicate pain or discomfort) | 1. Completely limited (Unresponsive –does not moan, flinch or grasp to painful stimuli due to diminished LOC or sedation, OR limited ability to feel pain over most of body surface) 2. Very limited (Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has sensory impairment that limits ability to feel pain or discomfort over half of body) 3. Slightly limited (Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has sensory impairment that limits ability to feel pain or discomfort in 1=2 extremities) 4. No impairment |
Moisture (Degree to which skin is exposed to moisture) | 1. Constantly moist (Skin constantly moist from perspiration, urine, drainage, etc. Moistness apparent every time patient moved or turned) 2. Very moist (Skin is often, but not always moist. Linen must be changed at least every 8 hours) 3. Occasionally moist (Linen change required every 12 hours. 4. Rarely moist (Skin usually dry: includes routine diaper changes. Linen changed every 24 hours. |
Friction (Occurs when skin moves against support surfaces)
Shear (Occurs when skin and adjacent bony surface slide across one another) | 1. Significant problem (Spasticity, contracture, itching, or agitation leads to almost constant thrashing and friction. 2. Problem (Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets impossible. Frequently slides down in bed or chair requiring repositioning with maximum assistance) 3. Potential problem (Moves feebly or requires minimum assistance. Skin slides against sheets, chair, restraints or other devices. Maintains good relative position in chair or bed most of the time) 4. No apparent problem. |
Nutrition (Usual food intake pattern) | 1. Very poor (NPO and/or on clear liquids or IVs for more than 5 days, OR never eat a complete meal. Rarely eats more than half of food offered. Protein intake only 2 servings meat or dairy per day. Takes fluids poorly. Does not take dietary supplement) 2. Inadequate (Liquid diet or tube feedings or TPN which provides inadequate calories and minerals for age, OR rarely eats a complete meal and usually eats about half of food offered. Protein includes 3 servings of meat or dairy products per day, will occasionally take a nutritional supplement) 3. Adequate (Tube feedings of TPN which provides adequate calories and minerals for age OR eats over half of most meals. Eats 4 servings of protein each day. Occasionally refuses a meal but will take a nutritional supplement. 4. Excellent (Normal diet providing adequate calories for age) |
| Tissue Perfusion & Oxygenation | 1. Extremely compromised (Hypotensive—MAP <50 mm Hg; <40 in a newborn, OR patient does not physiologically tolerate position changes) 2. Compromised (Normotensive oxygen saturation<95%; hemoglobin<10 mg/dl; capillary refill>2 seconds; serum pH<7.40) 3. Adequate (capillary refill = 2 seconds; serum pH is normal) 4. Excellent (Normotensive, oxygen saturation>95%, normal hemoglobin, capillary refill <2 seconds) |
REFERENCES
- Song E, Milne C, Whiston-Lemm K, Robinson S, Lebedinskaya N, Wong A, (2025). "Pressure Ulcers/Injuries - Prevention". In Rubayi S, (Eds.) , WoundReference.
- Barakat-Johnson M, Ryan H, Brooks M et al (2023). A ‘Quick Guide’ to Pressure Injury Management. Wounds International. [1]
- Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA; 2019. [2]
- Gefen, A., Alves, P., Ciprandi, G., Coyer, F., Milne, CT, Ousey, K., Ohura, N., Waters, N., Worsley, P. Device-related pressure ulcers: SECURE prevention. An International Consensus Statement. Journal of Wound Care. 2020;29(Sup2a):S1-S52. [3]
- Saindon, Kelly DNP, RN, CHPN; Berlowitz, Dan R. MD, MPH. Update on Pressure Injuries: A Review of the Literature. Advances in Skin & Wound Care 33(8):p 403-409, August 2020. | DOI: 10.1097/01.ASW.0000668552.48758.1c [4]
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
