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    Person Responsible - Flow Chart

    Uploaded by

    Leizyl Villasis
    The document outlines the steps a nurse takes to assess a patient's risk for developing pressure ulcers and to prevent pressure ulcers. The nurse performs a comprehensive skin assessment, notes any existing pressure ulcers, assesses risk factors using the Braden Scale, and develops a pressure ulcer prevention plan. The plan includes regular turning, using protective barriers and support surfaces, and providing health teachings to caregivers about prevention. For patients with existing pressure ulcers, the nurse documents the wounds and notifies the physician.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Person Responsible - Flow Chart

    Uploaded by

    Leizyl Villasis
    88 views4 pages
    The document outlines the steps a nurse takes to assess a patient's risk for developing pressure ulcers and to prevent pressure ulcers. The nurse performs a comprehensive skin assessment, notes any existing pressure ulcers, assesses risk factors using the Braden Scale, and develops a pressure ulcer prevention plan. The plan includes regular turning, using protective barriers and support surfaces, and providing health teachings to caregivers about prevention. For patients with existing pressure ulcers, the nurse documents the wounds and notifies the physician.

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    The document outlines the steps a nurse takes to assess a patient's risk for developing pressure ulcers and to prevent pressure ulcers. The nurse performs a comprehensive skin assessment, notes any existing pressure ulcers, assesses risk factors using the Braden Scale, and develops a pressure ulcer prevention plan. The plan includes regular turning, using protective barriers and support surfaces, and providing health teachings to caregivers about prevention. For patients with existing pressure ulcers, the nurse documents the wounds and notifies the physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    88 views4 pages

    Person Responsible - Flow Chart

    Uploaded by

    Leizyl Villasis
    The document outlines the steps a nurse takes to assess a patient's risk for developing pressure ulcers and to prevent pressure ulcers. The nurse performs a comprehensive skin assessment, notes any existing pressure ulcers, assesses risk factors using the Braden Scale, and develops a pressure ulcer prevention plan. The plan includes regular turning, using protective barriers and support surfaces, and providing health teachings to caregivers about prevention. For patients with existing pressure ulcers, the nurse documents the wounds and notifies the physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Person responsible

    Flow chart
    Start

    Receives Endorsement

    Pre assessment

    description
    Receives the patient upon
    admission or from transin.

    Nurse notes the name of


    the patient, age, diagnosis
    and history.

    Note the condition of the


    client and do history
    taking.

    Assessment

    *Nurse performs
    comprehensive head to
    toe skin assessment
    paying attention to the
    bony prominences
    *Nurse assess the existing
    pressure ulcers that
    started outside:
    - note the stage/depth
    (Location, size and shape,
    odor, exudate, color,
    condition surrounding the
    skin)
    *Notify the Physician of
    the existing problem
    - Do risk classification
    using the Bradens Scale
    Assessment

    1. Assess Sensory
    Perception
    -Ability to respond
    meaningfully to pressurerelated discomfort.
    2. Assess Moisture
    - the degree to which skin
    is expose to moisture
    3. Assess Activity
    - the degree of patients
    physical activity
    4. Assess mobility
    - ability to change and
    control body position
    5. Assess nutritional
    status
    -usual food intake pattern
    6. Friction and shear
    -

    *Check the hydration


    status
    *Check Laboratory Results
    *Classify Use the Braden
    Scale to assess the
    patients level of risk (low,
    moderate, high) for
    development of pressure
    ulcers. The evaluation is
    based on six indicators.
    *Make Pressure Ulcer
    Prevention and Treatment
    Plan
    *The nurse will do the
    following:
    1. Make turning schedules.
    2. Post a turning schedule
    at the bedside following
    an every two hours

    schedule to reduce
    pressure, friction and
    shear in position.
    3. The nurse must use
    lifters and elevation of
    head not more than 30
    degrees (unless
    contraindicated) reduce
    shearing and friction.
    3. The nurse should avoid
    massaging over bony
    prominences and
    reddened areas.
    4. The nurse minimizes
    force and friction when
    giving bed bath. Applies
    moisturizing agents that
    are fragrance-free and
    alcohol-free.
    5. The nurse should clean
    the skin gently. Nurses
    must provide absorbent
    under pads or dressing.
    Replace when damp or
    soaked. Avoid using
    diapers, panties and briefs
    (garters can cause friction
    and shear) .
    6. The nurse change the
    linen regularly especially if
    soaked.
    7. Place thin, small pillows
    between the knees.
    8. Use transfer devices
    such as mechanical lifts,
    surgical mattress and
    surgical slip sheets.
    9. Provide special
    mattress. Nurse can
    provide special cushions,
    a foam mattress pad, an
    air-filled or water-filled
    mattress.
    10. Use protective barriers

    such as liquid barrier


    films, hydrocolloids, or
    protective padding as
    ordered to reduce friction
    injuries.
    11. Apply topical agents
    as ordered such as
    calamine+zinc oxide.

    EVALUATE THE CLIENTS


    CONDITION AFTER THE
    GIVEN INTERVENTIONS

    PROVIDE HEALTH
    TEACHINGS TO THE
    FAMILY MEMBERS OR
    OTHER CAREGIVERS
    ABOUT PRESSURE
    ULCERS. (CAUSES,
    PREVENTION,
    ASSESSMENT, EARLY
    DETECTION, TREATMENT,
    ROLE OF GOOD
    NUTRITION, IMPORTANCE
    OF TURNING, TURNING
    SCHEDULE AND GOOD
    HYGIENE.

    IF WITH EXISTING
    DECUBITUS ULCERS THE
    NURSE SHOULD DO THE
    FOLLOWING:
    1.

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