Notes
- Inspect skin at beginning of each shift and document findings. More frequent (every 2 hr) assessments are required for debilitated Pts.
- Effectively manage urine and fecal incontinence.
- Clean skin promptly with mild, nonirritating, nondrying cleaning solution, and avoid friction during cleaning.
- Use topical moisture barriers and moisture-absorbing pads if incontinent.
- Position Pts to alleviate pressure and shearing forces.
- Reposition Pts every 2 hr while in bed and every hour while in chair.
- Teach Pt to shift weight every 15 min while in chair.
- Use appropriate positioning devices and foam padding.
- Do not use donut-shaped devices.
- Avoid positioning Pts directly on trochanters or directly on wound.
- Maintain lowest head elevation position possible to minimize sacral pressure.
- Use extra staff and appropriate lifting devices.
- Prevent contractures.
- Provide adequate hydration and nutrition.
- Do not massage reddened areas over bony prominences.