Assessing Pressure Ulcers Risk
OVERVIEW
- To provide a method for evaluating a patient for the presence of risk factors that could lead to the development of a pressure ulcer.
- To determine the presence of risk factors, provide a rationale for implementing preventive measures to avoid pressure ulcers, and maintain skin integrity.
- To perform a skin assessment for the presence of any lesions, ulcers, blisters rashes, warmth, redness, bruising, scaling, moisture, or dryness.
- Screen all patients on admission to determine the presence of risk factors that may result in a pressure ulcer. Note whether there is any history of a pressure ulcer or skin problem.
- Use a risk assessment tool to identify risk factors: immobility, inactivity, incontinence, malnutrition, friction, and shear.
- Perform a head-to-toe skin assessment to determine any abnormal skin findings: lesions, ulcers, blisters, rashes, warmth, redness, bruising, scaling, moisture, or dryness.
- Document all findings, be specific in describing any problems, and illustrate findings on the skin assessment form. (Forms vary according to facility.)
Image Source:http://www.pharmacy-technician.net
- Identify the patient at risk for developing a pressure ulcer, according to the Norton Scale, the Braden Scale, or the preferred risk assessment scale in the facility.
- Institute the protocol for prevention of pressure ulcers based on the risk assessment.
- Obtain specific skin care orders when there is a problem.
- Determine if there are other factors that may place the patient at risk for a pressure ulcer, such as altered mental status, unstable vital signs.
- Reassess every patient at least every 48 hours and perform risk assessment at any time when there has been a significant change in the patient’s condition to prevent skin breakdown.
- Continue to monitor and document the skin condition and report any change in skin integrity promptly to prevent a pressure ulcer.
- Always document any special protocols, including skin or ulcer care or special pressure-reduction mattresses or beds.
- Impaired Physical Mobility related to trauma, surgery, or neuromuscular deficit
- Impaired Skin Integrity related to prolonged pressure on joints and bony prominences
- Ineffective Communication related to illness
- Factors that place a patient at risk for developing a pressure ulcer will be recognized, reported, and documented
- Patient will be assessed for pressure ulcer risk in a timely manner, and a prevention plan will be instituted
- Patient will maintain optimal skin integrity
- Risk assessment tool (Norton Scale, Braden Scale, or specific risk assessment tool for facility)
- Standard facility admission form for documentation of skin assessment
- Nursing record or flow sheet for ongoing skin assessment
- Adequate lighting to perform thorough skin assessment
- Measuring device to document size of skin lesion, ulcer, or other abnormal finding
- Sheet or appropriate drape for patient comfort during the skin assessment
- Any Personal Protective Equipment (PPE), such as gloves, mask, gown, goggles, as indicated by patient’s diagnosis
- Perform skin assessment on admission, and complete admission assessment form. Explain procedure to patient and/or caregiver. Use clean gloves and/or any other PPE if indicated.
- Assess risk with risk assessment scale.
- Initiate prevention protocol based on risk assessment and risk factors identified. Check on prevention protocol and strategies.
- Document all preventive care or wound care if there is a skin problem.
- Communicate all skin care with nursing staff, and promptly notify the patient’s prescriber when there is a change in the skin condition. Prompt notification ensures that any necessary change will be made to reduce risk for further skin damage.
- Continue to assess the patient’s skin for changes: no blanching erythema, swelling, moisture may increase risk for a pressure ulcer. Skin assessment must be included in the head-to-toe assessment; regular skin assessment ensures that any change will be noted and prevention methods will be initiated.
- After completing assessment, remove gloves and PPE, and wash hands.
Categories:
Fundamentals In Nursing,
Physical Examination
1 komentar:
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
liver already present. I started on antiviral medications which
reduced the viral load initially. After a couple of years the virus
became resistant. I started on HEPATITIS B Herbal treatment from
ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their
treatment totally reversed the virus. I did another blood test after
the 6 months long treatment and tested negative to the virus. Amazing
treatment! This treatment is a breakthrough for all HBV carriers.
Posting Komentar