CMC Skin Integrity Bundle

S
Within 4 Hours Of
And Upon Discharge
Skin Assessment Admission And
To SNF Or Rehab
Transfer

A Assess Risk Use Braden Scale Consider Alternative

Risk Factors

V
Apply Protective
Vigilant Around & Under
Barriers When Alleviate Pressure
Monitoring Medical Devices
Appropriate

E Early Mobility
Promote Physical
Activity
Use BMAT

S
Waffle
Surface Select & Apply
Mattress/Seat, Low
Selection Appropriate Surface
Air Loss Mattress

K Keep Turning
Reposition At Least
Every Two Hours
Use Pillows And/or
Other Devices To
Alleviate Pressure

I
Use Absorbent Pads
Incontinence Provide Routine Keep Skin Clean And
& Barrier Creams To
Management Pericare Dry
Minimize Moisture

N Nutrition/
Hydration
Promote Oral/
Nutritional Intake
 Braden Risk Assessment Scale
SENSORY MOISTURE ACTIVITY MOBILITY NUTRITION FRICTION
PERCEPTION SHEAR

4. NO IMPAIRMENT 4. NO LIMITATION 3. NO APPARENT

4. WALKS FREQUENTLY
Makes major and 4. EXCELLENT PROBLEM
Responds to verbal 4. RARELY MOIST Walks frequently within
commands and feels frequent changes in Eats most of every Has sufficient muscle
Skin is usually dry. room and at least twice
and voices discomfort. position without meal. strength to lift up body
per day outside room.
assistance. when moving in bed.

3. SLIGHTLY LIMITED
3. OCCASIONALLY 3. WALKS 3. SLIGHTLY LIMITED
Responds to verbal 3. ADEQUATE 2. POTENTIAL PROBLEM
MOIST OCCASIONALLY Makes frequent though
commands but can’t Eats over half of most During move skin slides
Skin is occasionally Walks occasionally in slight changes in body
always communicate meals. to some extent.
moist. very short distances. or extremity position.
discomfort.

1. PROBLEM
2. OFTEN MOIST 2. VERY LIMITED 2. PROBABLY
2. VERY LIMITED 2. CHAIRFAST Skin slides during all
Makes occasional slight INADEQUATE
Responds only to painful Skin is often moist. Ability to walk severely movement with
changes in body or Rarely eats a complete
stimuli. limited or nonexistent. frequent sliding down in
extremity position. meal.
bed.

1. COMPLETELY 1. COMPLETELY
LIMITED 1. CONSTANTLY MOIST IMMOBILE 1. VERY POOR
1. BEDBOUND
Unresponsive. Doesn’t Skin is kept moist Does not make even Never eats a complete
Confined to bed.
moan/groan/flinch to almost constantly. slight changes in body meal.
discomfort. position.

NONE MILD MOD HIGH SEVERE

RISK SCALE 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6