Welcome back to my series addressing sepsis and why it is important to your cases. Feel free to email me with any questions you may have regarding the information I have provided or if you would like some help with one of your cases.

Today we are talking about Pressure injury wounds-

1. When should nursing assess for pressure injury wound development?
2. What nursing should be doing in the prevention of development,
3. Care plan assessment and prevention interventions
4. and the signs/ symptoms nursing should be looking for and assessing on a daily basis.

When should a nurse assess a patient for pressure injury wound potential?

1. Every new admission should be screened for potential risk of skin breakdown
2. Every transfer from another floor or facility and onto your assignment should be screened.
3. Every day, every shift, nursing should screen every resident/patient on their assignment.

This may sound overwhelming or daunting, but these assessments are quick and use elements of assessment that nursing should already be utilizing in their daily care of residents/patients.

These three key indicators pertain to all nurses – whether they work in a hospital, a nursing home, an LTACH, or a rehabilitation facility.

Admission to a facility or hospital and routinely thereafter, patients and residents are screened for risk of pressure injury wound development. There are many skin assessment tools that can be used – the Braden scale and Norton scale are two of the most common.   Nursing uses these tools to assess the risk the patient/ resident may have for developing pressure injury wounds. Based on this assessment, nursing creates a plan of care specific to the needs and initiates prevention interventions.

Depending upon the risk assessed, there are multiple interventions available to nursing that can be initiated. These include support surfaces such as a low air loss mattress, specialty pad for wheelchairs, Turning/repositioning every two hours, reducing shear when repositioning, daily inspection of bony prominence points and frequent incontinence checks. A stage one pressure injury wound is classified as redness over a bony prominence area with skin intact and blanching present.  This is nursing’s opportunity to prevent a pressure injury wound from developing.

If a pressure injury wound is potentially developing, Paige Legal Nurse consulting knows the nursing standard of care requires the care plan to be addressed and updated with preventative interventions put in place.  LPN’s can participate in the care plan process of assessment, planning, implementation, and evaluation and can contribute to the development, maintenance, or modification of the nursing component of the plan of care. They are then required to communicate the nursing component of the nursing care plan and all modifications of the plan to the members of the health care team.

The LPN has a limited role in each of these steps but cannot perform any of them completely or independently, an RN has the responsibility of completing them and the plan of care.  

A stage two pressure injury wound involves a break in the skin, whether it be a crack or a shearing of the skin, similar to a rug burn. Again the nursing standard of care requires the care plan to be addressed updated and the medical team immediately notified. A stage 2 pressure injury wound is now at high risk for worsening and it is critical for nursing to initiate aggressive preventive measures and monitoring.

Any resident who is bedbound is at that particular risk and requires the specific preventative intervention of turning and repositioning every two hours, this should be a scheduled and routine intervention. It only takes 2 hours of constant pressure over a bony prominence for a deep tissue wound to develop.