Pressure Ulcer Audit ED Admissions
Wound/ Pressure Ulcer Assessment: Four Eyes Audit Tool
Instructions: ED RN & Admitting RN assess the skin in the anatomical locations designated in the circles. Place your
initials on the circle over any area that has a Wound/ Pressure Ulcer . Describe any abnormalities.
 None Present
Description
1.
Occiput:
2.
Ear:
3.
Scapula:
4.
Spinous Process:
5.
Shoulder:
6.
Elbow:
7.
Iliac Crest:
8.
Sacrum/Coccyx:
9.
Ischial Tuberosity:
10. Trochanter:
11. Knee:
12. Malleolus:
13. Heel:
14. Toe:
ED RN Checklist

Admitting RN Checklist
Braden Risk Score Documented in Cerner
 Braden Risk Score Documented in Cerner
If Wound/ Pressure Ulcer Present
 IPOC Initiated for Risk for Altered Skin
 Wound/ PU Assessment Documented in Cerner
 Patient assessed for correct mattress surface (At risk pts
must have an Isoflex at minimum).
 ED Physician notified
 Mepilex Dressing applied to sacrum if any PU
Risk Factors Present (See reverse for risk factors)
 Mepilex Dressing applied to sacrum if any PU Risk Factors
Present (See reverse for risk factors).
If Wound/ Pressure Ulcer Present
Remember to: Date, time, initial, and write “T”
if treating a PU or “P” if used for prevention
with a marker on the dressing
 Wound/ PU Assessment Documented in Cerner
 Admitting Physician notified
 Photo Taken
ED RN Signature: ____________________
Date & Time ______________
Admitting RN Signature: ____________________ Date & Time ______________
Second ED RN Signature: _______________________ Date & Time ________________
Place Patient Sticker Here
 Mepilex Dressing applied to sacrum if any PU Risk
Pressure Ulcer Prevention Practice
Guidelines
Factors Present
(See reverse for risk factors)
Source: TriCityMedicalCenter.OceansideCA.2013
Remember to: Date, time, initial, and write “T” if treating a
PU or “P” if used for prevention with a marker on the
Pressure Ulcer Audit ED Admissions
1. The following Risk Factors place patients at higher risk for Pressure Ulcers:
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Braden Score Less than 18
Use of Vasopressors
Incontinent of Urine or Feces
Limited Self-mobility
Age 65 or greater
Diabetes
Prior Recent Hospital Stay
Shock/Sepsis
Recent Cardiac Arrest
Hx of Pressure Ulcers
Going to OR or Multiple Procedures Greater than 6 hours
Quad/ Para/ Hemiplegic
Stroke/ Paralysis
Obese/ Cachetic
2. Pressure Ulcer Prevention Intervention Guidelines
Area of Risk
Reduce Pressure (for
decreased sensation,
activity, or mobility)
Moisture Control
Reduce Friction & Shear
Encourage Good Nutrition
Interventions
Place patient on Inpatient Pressure Reducing Mattress
(Isoflex)
Place patient on overlay air mattress
Turn patient Q 2 Hours
Offer toileting Q 1hour
Check Continence Brief Q 2 Hours & Provide skin &
continence care
Keep Head of bed less than or equal to 30 degrees
Use Glide device for transfers
Offer fluids Q 1 hour
Set up for meals
Source: TriCityMedicalCenter.OceansideCA.2013