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P R E S S U R E
I N J U R I E S
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EVALUATING RISK
2 Patients, 2 Plans
Pressure Sore Risk"
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HANDLING HEELS Low-profile pillows provide
a simple way to prevent heel ulcers.
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Use the “Braden Scale For Predicting Pressure Sore Risk” (tinyurl.com/m3p65l6) to help formulate treatment plans that reduce the risk of pressure ulcers. Here are 2 examples you might encounter, along with suggested precautions.
• Mr. Adams is a 56-year-old man scheduled for abdominoplasty. He lost 100 pounds after having a lap band placed a year ago. Redundant skin on buttocks and sacrum were noted during pre-op skin inspection and risk assessment. His Braden Scale score is 18.
Risk factors:
• Inadequate nutrition
• Potential for friction/shear injury
• Linens could become wet during surgery due to perspiration and irrigation fluid
• Length of procedure is potentially longer than 3 hours
Plan:
• Moisture management: Absorbent pad on OR table and sacral dressing pre-op
• Reduce friction/shear: Use transfer sheet, avoid “dragging” during transfers. (Sacral dressing also protects skin from friction/shear forces)
• Hand-check redundant skin on sacrum and buttocks during positioning
• Protect heels: Use low-profile pillows under legs to “float” heels
• Perform post-op skin assessment
• Turn patient off his back as soon as tolerated in PACU
• Ms. Bates is a 32-year-old woman scheduled for laparoscopic cholecystectomy. Her skin is intact on pre-op assessment. Her Braden Scale score is 23.
Risk factors:
• Friction/shear forces are always a risk when transferring anesthetized patients
Plan:
• Use lateral transfer sheet and avoid dragging
• Perform post-op skin assessment
• Turn patient off her back as soon as tolerated in PACU
— Anne Nowlin, RN, CNOR,
and Ann Marie Whaley, RN, CWOCN
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