~ SAMPLE POLICY & PROCEDURE ~
Patient Management for the Prevention of Pressure Ulcers
POLICY
It is the policy of _______________ to minimize the risk of pressure ulcers by utilizing
precautionary interventions on all vulnerable patients.
PURPOSE
To prevent pressure ulcer formation by identifying those patients who are at risk for pressure
ulcer development and by aggressively intervening to minimize actual and potential risks for
skin breakdown.
DEFINTIONS
1. Therapeutic Mattress – Pressure reducing or relieving surface.
2. Pressure Reducing – Surface that relieves the pressure beneath the patient’s body, BUT it
does not consistently maintain interface pressures below capillary closing pressure.
3. Pressure Relieving – Surface that relieves the pressure beneath the patient’s body AND
consistently reduces interface pressure to a level below capillary closing pressure.
4. Capillary Closing Pressure – Pressure applied to the capillary bed that is sufficient to
collapse the capillaries; pressure commonly considered to be 25-32 mmHg in a healthy
individual, but lower in a compromised individual.
PROCEDURE
A. Complete the “enhanced” Braden Risk Assessment on admission and at regular intervals for
all adult inpatients.
B. All patients should be reassessed using the Braden Risk Assessment after any surgical
procedure and/or when their condition changes relative to sensory perception, moisture,
activity, mobility, nutrition, friction and shear.
C. Implement preventative interventions according to the Protocol below.
Plan interdisciplinary care for patients with identified risks and problems, i.e., ensure
appropriate nutritional intake; improve or maintain activity level; assess, treat, and protect
skin daily.
NURSING GOAL is to minimize Capillary Closing through preventive interventions.
PREVENTION PROTOCOL
Braden Scale Score
Definition
MODERATE RISK
VERY HIGH RISK
EXTREMELY HIGH
RISK
20 – 18
17- 15
14 or Less
Without intervention, this
patient has up to a 50%
chance of skin breakdown
Without intervention this
patient has a 50% to 65%
chance of skin breakdown
Pressure Reducing
Therapeutic Mattress
INTERVENTIONS
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Turn / Move q 2 hrs
Position patient 30
degrees on his side, not
directly on trochanter
Keep bed at 30 degree
angle or less to reduce
friction & shear (unless
contraindicated).
Use pillows or pads to
separate skin surfaces
and support limbs
Reposition q 1 hr in
chair, shift every 15
minutes
Free float heels
Care plan for any
Braden criteria <3
Do not use donut
devices
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Pressure Relieving
Therapeutic Mattress
Use Pump
Turn q 2 hrs in bed
Position patient 30
degrees on his side,
not directly on
trochanter
Keep bed at 30 degree
angle or less to reduce
friction & shear
(unless
contraindicated).
Use pillows or pads to
separate skin surfaces
and support limbs
Reposition q 1 hr in
chair, shift every 15
minutes
Free float heels
Care plan for any
Braden criteria <3
ET Consult
Do not use donut
devices
Without intervention, this
patient has a 66% to
100% likelihood of skin
breakdown
Pressure Relieving
Therapeutic Mattress
Use Pump
 Turn / Move q 1 hr
 Position patient 30
degrees on his side,
not directly on
trochanter
 Keep bed at 30
degree angle or less
to reduce friction &
shear (unless
contraindicated).
 Use pillows or pads
to separate skin
surfaces and support
limbs
 Reposition q 1 hr in
chair, shift every 15
minutes
 Free float heels
 RD Consult
 ET Consult
 Care plan for any
Braden criteria <3
 Do not use donut
devices
Braden Re-Assess
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Every other day
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Every other day
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Every day
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Examine skin daily
Clean skin at time of
soiling & at routine
intervals
Use warm, not hot,
water
Use a mild cleansing
agent
Minimize factors
leading to dry skin
(humidity 40 %)
Moisturize dry skin
Don’t massage bony
prominences.
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Examine skin daily
Clean skin at time of
soiling & at routine
intervals
Use warm, not hot,
water
Use a mild cleansing
agent
Minimize factors
leading to dry skin
(humidity 40 %)
Moisturize dry skin
Don’t massage bony
prominences.
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SKIN CARE
Examine skin each
shift
Clean skin at time of
soiling & at routine
intervals
Use warm, not hot,
water
Use a mild cleansing
agent
Minimize factors
leading to dry skin
(humidity 40 %)
Moisturize dry skin
Don’t massage bony
prominences
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