1. Updated September 2011

2. Cleanse
Moisturize
Protect
Be Gentle

3.  Complete and document a skin assessment on
admission and daily
 Note whether or not wounds and pressure
ulcers are present on admission (POA)
 Complete the Pressure Ulcer Risk Assessment
Tool: The Braden Scale
 Document and stage all pressure ulcers using
the NPUAP* Staging system
*National Pressure Ulcer Advisory Panel

4. ◦ The Braden Scale score will help identify patients
at risk for developing pressure ulcers
◦ Score of 12 or less indicates your patient is at
high risk for pressure ulcer formation
◦ Initiate interventions targeted at the areas in
which your patient achieved lower scores

5.  Measure and document wounds when discovered
and every Wednesday. Document length, width,
and depth in cm
 Document appearance of wound bed, odor,
drainage, and condition of surrounding skin
 Consider a multidisciplinary approach to include a
dietitian, physical therapist, or an occupational
therapist to optimize wound healing

6.  Repositioning
 Position patients off of affected area(s) if pressure ulcers are present
 Position patients at a 30-degree angle when on their sides
 Avoid raising the head of the bed (HOB) higher than 30 degrees
 Use pillow between knees and ankles when on their sides
 Use safe patient handling equipment to move patients
 Apply barrier cream to buttocks if patient is incontinent of urine or stool
 Float heels off the bed surface

7.  All interventions implemented
 Barriers to implementation (for example, a patient’s
unstable hemodynamics may make it impossible to
reposition him/her as often as is needed for skin
integrity)
 Patient and caregiver’s willingness to accept
interventions
 Patient and caregiver education provided regarding
skin integrity

8. Every nurse should initiate the standing skin
care orders for
 Stage I pressure ulcers
 Stage II pressure ulcers
 Skin tears
 Standing Skin Care Orders are located on every
department and can also be found in the section
entitled “Reference Documents” on every computer

9. 1. Click on MCHS intranet icon (soon to be
Cone Health icon)
2. Click on Resources
3. Click on Reference Documents
4. Click on Clinical Resources
5. Click on Wound Ostomy Care

10.  Involves inspecting the skin of every patient in our
hospitals on the same day to provide an accurate “snap
shot” of the number of patients who have pressure
ulcers
 Quarterly measuring of PUP is a requirement for all
Magnet™ hospitals
 Hospital Acquired Pressure Ulcers are considered
“Never Events” by The Joint Commission
 Cone Health’s Goal= 0%
 This is an opportunity for you to participate in research
that improves patient care

11. Wound Ostomy Continence (WOC) nurse
consults require a physician’s order
Appropriate consultations include:
Stage III or IV pressure ulcers
Patients with new ostomies
Patients with established ostomies who are having problems
New placement of negative pressure wound therapy
Complex lower extremity wounds