Inpatient Wound Care Objecti Jennifer Celtrick 1 Mon. Tues. AM 7NW 1, What does the Braden score have to be to deem a patient high risk for pressure ulcers? The Braden skin scale takes into account 5 areas of risk for pressure ulcer development: a. Sensory- Cognition and the ability to sense discomfort and pain b. Moisture- Is the patient prone to excessive moisture such as with incontinence of urine and/or stools or the requirement of frequent linen changes. ©. Activity- Is the patient up ad lib, chair fast, bedfast etc... d. Nutrition Does the patient eat well or not to maintain their body's needs. @. Friction and Shear- Is the patient able to reposition themselves or do they require assistance Any patient who scores at 18 or below will be put on pressure ulcer precautions. 2. Name 4 interventions a nurse can do to prevent pressure ulcers. a. Q 2hrturns b. Offload the heels ie... boots c. Nutrition . Hydration 3. Name 2 of the most common sites for pressure ulcers to occur. a. Coccyx/Sacrum b. Heels: 4, Name 3 common causes of skin tears. a. Being elderly b. Steroids: thin skin ¢. Poor nutrition and hydration 5. Name 3 interventions that a nurse can do to prevent skin tears. a. Moisturize the skin b. Ensure adequate nutrition and hydration c._ Long sleeves/pants- less exposed skin