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NOTE: The electronic version of this document or form is the latest and only acceptable version. You are responsible to ensure anyprinting of this document is identical to the e-version.SKIN CARE: PRESSURE INJURY PREVENTIONClinical ProtocolApproved: March 2020Next Review: March 2023Clinical Area: All inpatient clinical and emergency department areasPopulation Covered: All Adult and Pediatric Inpatients and Emergency Department patientsCampus:Ballard, Cherry Hill, Edmonds, First Hill,Issaquah, Mill Creek, RedmondImplementation Date: January 2002Related Procedures, Protocols, and Job Aids:Camera Photography, Video and Audio RecordingSacral Dressing Application for Pressure Ulcer PreventionVacuum Assisted Wound Closure (VAC) Therapy ManagementWound Management: ComplexUsing Digital Photography for Patient Care (Haiku Photo Capture)Perineal Skin Care/Diaper Dermatitis Management Guideline for Neonates and Diapered ChildrenSkin Injury Prevention Related to Respiratory TherapyGo directly to:Patient AssessmentBasic Skin Care / Pressure Ulcer BundleSkin and Wound TreatmentBraden ScoringDefinitionsMoisture Associated Skin Damage (MASD)Nail CareSkin TearsPressure Injury Debrief and HandoffPurposeTo provide guidelines for assessment, prevention, and interventions of common skin-related issues.Policy StatementNone.LIP Order RequirementElements of this protocol require a licensed independent practitioner’s (LIP) order.Responsible PersonsRN, LIP, Nursing Assistants (NA-C), Wound Ostomy Nurse (WON)Clinical Protocol: SKIN CARE: PRESSURE INJURY PREVENTION 2020 Swedish Health ServicesPage 1 of 9

Prerequisite InformationIdentification of the patient who is at risk for the development of pressure injury is essential to the success of anyskin care program. Risk factors including immobility, pressure, friction, shear, nutritional deficit, sensory deficit,inactivity, dehydration, edema, incontinence, excess moisture, diabetes, vascular disease. 6. IIAThe Braden Scale for predicting pressure injury risk is a validated tool that allows nurses to reliably score adultpatients level of risk for developing pressure injuries. 1. IVAThe Braden QD Scale is a validated tool that allows nurses to reliably score pediatric patients level of risk fordeveloping pressure injuries.The incidence of pressure ulcers and their complications can be significantly reduced with optimal nursingintervention, combined with patient and caregiver participation and education. 6. IIAPressure injuries generally develop over bony prominences and are an ischemic response to sustained pressureand/or damaging forces (shear, friction, moisture). This ischemic response can result in soft tissue death. 6. IIAPROCEDURE or PROTOCOL Requires an LIP orderResponsiblePersonStepsPATIENT ASSESSMENTRNBony prominence sitesInitial skin assessmentA skin assessment is performed and documented within 12 hours of admission on all patients,as well as prior to any elective procedure. Assessment head to toe and front to back skinassessment includes:Clinical Protocol: SKIN CARE: PRESSURE INJURY PREVENTION 2020 Swedish Health ServicesPage 2 of 9

1.Examination under skin folds, under all potential pressure points, and under anydevices, unless contraindicated due to physiologic instability.2.The RN completes the admission screening, the Braden Scale (adults) and Braden QD(pediatrics), and the skin/wound assessment in the electronic medical record (EMR).NOTE: For pediatric and neonatal patients, review the visual aids in the Skin InjuryPrevention Related to Respiratory Therapy policy.NOTE: A pressure injury documented within 24 hours of admission is consideredpresent on admission (POA). 2. National GuidelinesRN, LIP3.to beIf the patient is found to be at risk for developing a pressure injury, the Pressure InjuryPrevention Bundle is initiated. Criteria for initiation of the bundle include: Braden scale of 18 or less (adults)Two of the sub-scores of the Braden have scores of 2 or less (adults)Braden QD Scale of 13 or greater (pediatrics)The Pressure Injury Bundle includes five elements: 1) Skin prophylaxis, 2) Pressureredistribution, 3) Positioning, 4) Moisture management, and 5) Nutrition support.4.If the patient is admitted with a dressing, it should be removed by the RN to assess theskin unless contraindicated. Examples of possible exceptions include: Stabilizing bracesNegative pressure therapy dressings (VAC)NOTE: RN should clarify exceptions with the LIP. If a VAC dressing has beenin place longer than outlined in the Vacuum Assisted Wound Closure (VAC)Therapy Management policy for frequency of dressing changes, the LIP shouldbe notified. 5.RN, LIP, WONReview orders for surgical wounds or patients post procedure, as these may havebeen placed by the LIP post procedure.Each alteration in skin integrity (pressure-related and non-pressure-related) must have anew LDA added in the EMR. At a minimum, the RN is expected to document thelocation, measurements and color of the wound bed, and actions or interventions taken.Each dressing change is dated and timed on the dressing and documented in theflowsheet.Pressure Injury assessmentIf the patient has a pressure injury present on admission (POA) or develops a hospitalacquired pressure injury (HAPI):See addendum, Present on Admission: Pressure Ulcer Documentation Process.1.2.Notify LIP of pressure injury (POA or HAPI). The LIP is responsible for documentingthe POA pressure injury in the admission history and physical (H&P). 2. National GuidelinesAt a minimum, the RN is expected to document the location, measurements and colorof the wound bed, and actions or interventions taken upon discovery of the pressureinjury. 6. IIAClinical Protocol: SKIN CARE: PRESSURE INJURY PREVENTION 2020 Swedish Health ServicesPage 3 of 9

3.4.5.6.7.The bedside nurse may identify and document Stage 1 pressure injuries. Remove thepressure source from the area (i.e., turn patient or reposition). Wait 30 minutes andthen reassess the wound by testing for blanchability. 6. IIAAside from Stage 1 pressure injuries, the pressure injury is staged by a WON and thoseRNs who have completed pressure injury staging education modules with documentedcompetency.A wound care consult is needed for any injury other than a Stage 1.Photograph the injury and placing the picture into the EMR. See Using DigitalPhotography for Patient Care (Haiku Photo Capture).If the pressure injury is hospital acquired: the nurse is to initiate the Pressure InjuryDebrief and Handoff. This form is to be completed, a copy is to be provided to the unitmanager, and the original is to accompany the patient should the patient transfer toanother unit. The checklist should be completed, which includes initiating an eQVRand obtaining a wound care consult.Ongoing skin assessmentRNOngoing assessment is completed by the RN a minimum of every shift and documented in theassessment flow sheet of the EMR. The documentation includes any alteration in skin integrity,new risk factors, and actions taken. The pressure injury prevention bundle is initiated if thepatient is found to be at risk: Braden scale of 18 or less (adults)Two of the sub-scores of the Braden have scores of 2 or less (adults)Braden QD Scale of 13 or greater (pediatrics)BASIC SKIN CARE / PRESSURE INJURY BUNDLERN, LIPPatients at SMC will receive basic skin care. Elements of this include:Skin Prophylaxis1.2.3.Consider the use of certain devices for prevention of pressure injury. These devicesinclude a silicone bordered sacral dressing (see Sacral Dressing Application forPressure Ulcer Prevention). 4. IVBOff-loading cushions for chairs. 4. IVBUse of pillows and protective heel boots to float heels or other areas. Use of thesedevices is particularly important in patients who are at high risk for pressure injury.4. IVBNOTE: The use of such devices does NOT replace regular skin inspection andfrequent repositioning. 4. IVBPressure redistribution1.2.3.4.5.Most adult and bedded pediatric patients at SMC are on a low air loss/pressureredistribution surface. Some patients will need alternative surfaces based on specialneeds (i.e. bariatric surface). 4. IVBUse single-layer breathable pads. There should be no more than 3 layers of pads and/orlinens between the patient’s skin and the air mattress.Protect the patient from lying on lines, tubes and wrinkled linen.4. IVBPosition to avoid allowing the body tissue to be compressed or under pressure from bedrails, arms of chairs, etc. 4. IVBRegardless of Braden Score or Braden QD score, all efforts should be made to reducepressure over bony prominences and under medical devices.4. IVBNOTE: The turn assist feature on beds does not offload the sacral pressure. Thisfeature should primarily be used during the physical act of turning the patient tohelp the staff member with the turn. 4. IVBClinical Protocol: SKIN CARE: PRESSURE INJURY PREVENTION 2020 Swedish Health ServicesPage 4 of 9

NOTE: Head of Bed greater than 45 degrees should be avoided for extendedperiods of time to minimize sacral pressure. As warranted by patient conditionand LIP orders, alternatives to this are HOB at 30 degrees and ReverseTrendelenburg. 4. IVBHead of bed, bassinet, crib for pediatrics is patient dependent. If they are on theventilator-associated prevention protocol, review Ventilator-AssociatedPneumonia (VAP) Bundle: Pediatric.NOTE: Specialty beds, including air fluidized beds do not eliminate or minimizethe frequency of the turning and repositioning requirement.Positioning (EMR: Keep Turning/Repositioning)1.RN, LIP2.RN, LIPAll patients, regardless of presumed ability, may need assistance withpositioning.6. IIAA turn schedule is initiated if the patient has a total Braden score of 18 or less, or a subscore of 2 or less in the mobility, sensory, and/or activity categories for adult patientsand a Braden QD of 13 or greater for pediatric patients. Turn every 2 hours, howeverpatients may be turned more frequently based upon individual need. 6. IIANOTE: All actual positions must be documented if the patient is on a turnschedule.For adult patients, if the Braden score is 18 or less and the patient is able to turn themselves,their actual position will need to be documented every 2 hours. If the patient does not turnthemselves every 2 hours, the RN should prompt the patient to turn. 6. IIANOTE: If an adult patient refuses a turn and has a Braden score of 18 or less, therefusal should be documented. Notify the LIP for ongoing refusal to turn.4.When a patient is in the chair, shift the patient’s weight every two hours.4. IVBMoisture management1.2.Bathing: Use disposable washcloths, cleansing foam and pre-moistened wipes forbathing. The use of pH (hydrogen ion concentration) neutral soap is encouraged. Useof wash basins is discouraged due to infection control.Incontinence hygiene:a.b.c.d.e.Patients who are incontinent should receive prompt care to avoid skinbreakdown. This includes, but is not limited to toileting schedules andmoisture barrier products.Do not use adult briefs unless the adult patient is out of bed.While in bed, one incontinence pad is preferred under the patient.Do not leave a patient on a bedpan for greater than 10-15 minutes.Use moisture protection devices, creams, ointments to keep skin folds dry,change as needed.Nutrition1.2.For adults with a Braden Nutrition subscore of 2 or less, a nutrition consult should beplaced in the EMR.3. IIIA Pediatric patients receive a nutrition review, but if the nurse isconcerned, they may place a nutrition consult.Consider lab values that may indicate nutritional risk (i.e. Albumin, Prealbumin,Hemoglobin A1C, and Transferrin). Patients with disease processes which may causenutritional compromise should be considered at risk also (i.e. Renal Disease, Cancer,Crohn’s disease, etc.).3. IIIAClinical Protocol: SKIN CARE: PRESSURE INJURY PREVENTION 2020 Swedish Health ServicesPage 5 of 9