1

inspection: inspect his skin color any sores 

pressure ulcer assessment: Braden Scale for Predicting Pressure Sore Risk
MOBILITY
NUTRITIONAL STATUS
 Wound Assessment 

2
Culture

3
NORMAL saline

4
Scrup

5
PPE

6
Changes in Health State Dehydration or malnutrition
Reduced sensation
Bed rest

Maceration
Age
Friction and Shear

satge 1 
8
B-D

9
Yellow Cleanse Yellow color in the wound may indicate the presence of exudate (drainage) or
slough and requires wound cleaning.
These wounds are characterized by oozing from the tissue covering the wound, often
accompanied by purulent drainage. Drainage can be whitish yellow, creamy yellow, yellowish
green, or beige. To cleanse these wounds, nursing interventions include the use of wound
cleansers and irrigating the wound

10

. Completely Limited= 4
. Constantly Moist= 1
. Chairfast= 2
. Very Limited= 2
nutrition=1

friction and Shear= 1

very high risk
19-23 Not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk ≤ 9 very high risk

11

pain
Anxiety and Fear
Changes in Body Image
External Pressure

12
It should be incorporated into the overall treatment plan based on the patient’s reported pain
level and assessment of the patient.

13

antimicrobials, such as: SilvaSorb Acticoat Excilon Silverlon

Antimicrobial or antibacterial action • Reduce infection • Prevent infection

14

‫كله‬

15

• Disturbed Body Image • Impaired Skin Integrity • Deficient Knowledge • Activity Intolerance related to
wound care • Self-care Deficit • Acute Pain • Risk for Impaired Skin • Chronic Pain Integrity • Impaired
Tissue Integrity • Risk for Trauma • Readiness for Enhanced Knowledge: Wound Care may be
appropriate for patients who request information about wound care at home

16

The patient will: • Maintain skin integrity • Demonstrate self-care measures to prevent pressure ulcer
development • Demonstrate self-care measures to promote wound healing • Demonstrate evidence of
wound healing • Demonstrate increase in body weight and muscle size, if appropriate • Remain free of
infection at the site of the wound or pressure ulcer • Remain free of signs and symptoms of infection •
Experience no new areas of skin breakdown • Verbalize that the pain management regimen relieves
pain to an acceptable level • Be discharged to home within established parameters • Demonstrate
appropriate wound care measures before discharge • Verbalize understanding of signs and symptoms to
report and necessary follow-up care

17

Teach patients about their health conditions and provide information and support to improve health
literacy by their patients.

18

shear and friction

19
Hand hygiene

20
Dietation
21
reassessment at regular intervals to monitor response to the treatment, determine the effectiveness of
the treatment, and allow for necessary changes in the plan of care

if no complications have occurred during wound healing, wound is progressing through the healing
stages, and the patient or family has the knowledge and skill necessary for wound care at home, if
appropriate

22

BCDA