• Patient Positioning:

• Turn all immobile patients at least every 2 hours or timed with Care (i.e. ordered touch times)

• Document “reposition-self” if patient is thoroughly able to do so on their own

• If unable to turn, document “unable to turn/pressure redistributed,” (i.e. turn hip, turn head, heels free

floating, arm elevated, etc.). MD order must be present.

• Maintain HOB less than or equal to 30 degrees (unless medically contraindicated)

• Patients that are able to get out of bed may sit in a chair or upright in bed. Chair bound patients’ weight

should be redistributed every hour. If patient able to redistribute their own weight, should be taught to do

so every 15 minutes

Reposition and document with

every touchtime

Appropriate Bed Surface:• Evaluate need for specialty bed if Braden Q score is less than or equal to 21• Consult MD/NP for use of appropriate bed, order must be placed under specialty bed• Offload bony prominences with gel pads, pillows, and/or pressure reduction device (gel pads must be remolded minimally

hourly). Protect at risk bony prominences with Protective/Preventive dressings (i.e. site of previous skin breakdown/pressure injuries, under C-collar or clinical judgment). Dressing must be dated & changed weekly unless soiled

Extra protective cream

must be applied every

diaper change on all

diapered patients and

documented

IMPORTANT

Remember if you didn’t document

you didn’t do it !!!

DOCUMENT! DOCUMENT!

DOCUMENT!

SkinDamage

Moisture

Friction

Shear

Pressure

• All breakdowns and pressure

ulcers must be documented in

PEDS under Assessments and

Skin abnormality every shift.

• Make sure to fill out an

incident report located in the

portal

• Make sure to fill out an SBAR

form and give to CS

Wound Care/Pressure Ulcer BundleSkin Assessment/Documentation

Modified Braden Q Scale:

Infants >1 month or >44 weeks corrected gestational age

First encounter of the shift

Assess Q12 hours if:

Score >21-(Non-Risk Patient)

Assess Q4 hours if:

Score < or = 21 (At Risk Patients)

Perfusion Compromised Patients

Surgery or Procedure > 4 hours

Neonatal Skin Score:

Infants < 1month or < 44 weeks corrected gestational age

First encounter of the shift

Device Rotation Assess skin Q 4 hours

Rotate medical device Q6 hours & DOCUMENT

Patient Positioning Document “Reposition Self” is able to do so.

If unable to reposition Self:

Immobile Patients- Document Q2 hours or with Q Touch Time

Unable to Reposition Patient-MD order MUST be present!!

Document “Unable to turn/Pressure Redistributed

Maintain HOB < or = 30 degrees-unless contraindicated

Bed Surface If Braden Q < or = to 21-Evaluate the need for a Special Bed/Obtain order.

Offload bony prominences with gel pads/pillows/pressure reduction devices-gel pillows

must be remolded HOURLY!

Use Protective/Preventive dressings for “At Risk” bony prominences-Dressing must be

dated and changed weekly!

Moisture Management ALL diapered patients- Protective Barrier Cream Q Diaper Change & Document under

Personal Care Provided in Treatment and Care Tab

Keep skin CLEAN & DRY!

Reminder: NOT CHARTED, NOT DONE!!!