Risk for activity or mobility deficit?

Yes

Yes

No

Reassess periodically.

Provide teaching.

End

Reassess periodically.

Consult a nutritionist for a nutritional assessment.

Increase protein intake and increase calorie intake, if needed.

Maintain adequate hydration.

Cleanse skin immediately with warm water or commercial skin cleanser. Do not use soaps that may alter the pH.

Reassess periodically.

No

Yes

Protect skin with a commercial barrier product

Offer a bedpan or urinal at regular intervals

If necessary, use asorbent briefs that are designed to wick & trap moisture away from skin
For skin folds, consider wicking textile product

Elevate the head of the bed no more than 30 degrees.

Reassess periodically.

Yes

No

Use preventive devices, such as a turn sheet or mechanical lift device.

Cover bony prominences with pressure redistriuting foam and keep the patient's heels off the bed.

Develop a turning schedule based on the patient's needs.

Consider using a patient monitoring position system to maintain the desired turn schedule

Consult a wound care specialist for appropriate pressure re-distributing devices and surface and for further assessment.

Consult a physical therapist to help increase mobility.

Assess pressure injury risk using an assessment tool.

Incontinence or moisture problems?

Sensory perception, mobility, and activity deficits?

Nutritional deficits?

Yes

No