Some ideas please?



My facility is looking at Wound Care Prevention. Our concern is that things are not being caught on admission and preventive interventions are not being utilized until AFTER there is an issue. How does you facility handle this? What do you implement immediately? This is geared more toward prevention than someone that has a wound.

Any info would be GREATLY appreciated!!

Every resident should have their skin assessed upon admission and every bath/shower day. Aides should be taught of the signs of the beginning of a pressure ulcer - redness, non-blanchable; signs of a blister starting.

nightmare, RN

2 Articles; 1,297 Posts

Specializes in Nursing Home ,Dementia Care,Neurology..

We have to assess skin in the first few hours of admission.All bruises ,blemishes and actual wounds/broken areas are documented and a detailed plan of skin care drawn up for that resident.

CapeCodMermaid, RN

6,089 Posts

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

You need a skin care protocol based on the Norton Plus or Braden Skin assessment. In my facility, anyone who scores 15 or less gets protective ointment twice a day. If the score is less than 10 a more intensive protocol is started. Try a team approach....nursing of course, dietary and PT/OT for help with positioning ideas. Your CNAs are worth their weight in gold. They should look at every resident's skin every shift and let someone know if there is a red mark or bruise or what ever. We use the CareTracker system. They have to document that they've checked the skin and if there is a new problem, they must document which nurse they told. If you don't have a computerized system, there are forms in duplicate on which the CNA can document any issue. They give a copy to their nurse and keep a copy to prove that they've told someone. Can't say enough about good old fashioned nursing care. All the pressure relieving mattresses won't help someone if they are never repositioned or if they are kept in a wet brief.

Sorry to go on, but I am passionate about pressure ulcer prevention.


520 Posts

Thank you CapeCod...That was along the lines of what I was looking for. We use the Braden Scale at our facility. We want to really push prevention. Good old fashion nursing care :yeah: We will never have the $$ for anything high tech or fancy. Nurses are doing the admission assessment, documenting high risk for breakdown, but not putting any interventions into place. Our aids are really great about notifying the nurses about issues, but I want to really try to prevent these issues.

Thanks for the input!!


61 Posts

Specializes in Geriatric/Psych.

Upon admission we put all our residents on MVT c min., Vit C, Vit E(unless on 'thinner') for prevention. Just a tidbit. Anyone who at risk is put on 4 oz of HPS at med passes.

CapeCodMermaid, RN

6,089 Posts

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

I wouldn't recommend putting all new admissions on extra vitamins. Read the latest studies...they aren't all that helpful or well absorbed in the elderly. Most of the residents take way too many medications and vitamins aren't really that essential.

CoffeeRTC, BSN, RN

3,734 Posts

Has 25 years experience.

First things first...Assessment. If you don't catch them on admit, the facility eats the wound. CNAs need to be looking at the skin daily and reporting to the nurses. We do weekly skin checks by the nurses on shower days too. We also to the Braden scale on admit (but that assessment is really only looked at by the RNAC) Care plans are generated by the risk score.

The dietician reviews all admits and will put them on MVIs and a supplement. Normally if we notice that they have poor labs, poor po intake or have an actual decub we will suggest to the MD on admit to put them on the supplement (we use Resourse 2.0)

The rest is basic...clean them, feed them move them.

A basic turning or repositioning schedule should be started. Post it in the rooms or where ever you need to. Some places are opposed to a schedule because that holds them accountable for keeping up with the schedule, I think it makes it easier to monitor the care. Make sure you have positioning devices...pillows or wedges, etc.

Get PT/OT involved. On admit or as soon as we see a skin issue we will send them a form to see if they can screen them for therapy or positioning assist.

A good basic barrier cream is great for prevention. Good old Zinc Oxide or A and D is the basics and can go up from there. We don't use any specialized incontinace cleansers either. Anyone who is inct starts off with these basics.

Specializes in Cardiac/Step-Down, MedSurg, LTC. Has 6 years experience.

Butt paste FTW!


29 Posts

I agree about vitamin orders. While Vit. C is certainly a good thing and is water soluble, labs must be looked at to adjust vitamin supplements as necessary, they can also have adverse reactions for some patients depending on their diagnosis'. Although the are "just" vitamins, they can harm as much as help too.


43 Posts

Specializes in LTC.

Part of your admission assessment sould be a complete skin survey.. Check every nook and cranny and move a few things if you have to. Measure everything with a real tape measure don't guestimate. per Cape Cod> Braden Scale is a great tool. Good luck to you

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