Person responsible

Flow chart
Start

Receives Endorsement

Pre assessment

description
Receives the patient upon
admission or from transin.

Nurse notes the name of

the patient, age, diagnosis
and history.

Note the condition of the

client and do history
taking.

Assessment

*Nurse performs
comprehensive head to
toe skin assessment
paying attention to the
bony prominences
*Nurse assess the existing
pressure ulcers that
started outside:
- note the stage/depth
(Location, size and shape,
odor, exudate, color,
condition surrounding the
skin)
*Notify the Physician of
the existing problem
- Do risk classification
using the Bradens Scale
Assessment

1. Assess Sensory
Perception
-Ability to respond
meaningfully to pressurerelated discomfort.
2. Assess Moisture
- the degree to which skin
is expose to moisture
3. Assess Activity
- the degree of patients
physical activity
4. Assess mobility
- ability to change and
control body position
5. Assess nutritional
status
-usual food intake pattern
6. Friction and shear
-

*Check the hydration

status
*Check Laboratory Results
*Classify Use the Braden
Scale to assess the
patients level of risk (low,
moderate, high) for
development of pressure
ulcers. The evaluation is
based on six indicators.
*Make Pressure Ulcer
Prevention and Treatment
Plan
*The nurse will do the
following:
1. Make turning schedules.
2. Post a turning schedule
at the bedside following
an every two hours

schedule to reduce
pressure, friction and
shear in position.
3. The nurse must use
lifters and elevation of
head not more than 30
degrees (unless
contraindicated) reduce
shearing and friction.
3. The nurse should avoid
massaging over bony
prominences and
reddened areas.
4. The nurse minimizes
force and friction when
giving bed bath. Applies
moisturizing agents that
are fragrance-free and
alcohol-free.
5. The nurse should clean
the skin gently. Nurses
must provide absorbent
under pads or dressing.
Replace when damp or
soaked. Avoid using
diapers, panties and briefs
(garters can cause friction
and shear) .
6. The nurse change the
linen regularly especially if
soaked.
7. Place thin, small pillows
between the knees.
8. Use transfer devices
such as mechanical lifts,
surgical mattress and
surgical slip sheets.
9. Provide special
mattress. Nurse can
provide special cushions,
a foam mattress pad, an
air-filled or water-filled
mattress.
10. Use protective barriers

such as liquid barrier

films, hydrocolloids, or
protective padding as
ordered to reduce friction
injuries.
11. Apply topical agents
as ordered such as
calamine+zinc oxide.

EVALUATE THE CLIENTS

CONDITION AFTER THE
GIVEN INTERVENTIONS

PROVIDE HEALTH
TEACHINGS TO THE
FAMILY MEMBERS OR
OTHER CAREGIVERS
ABOUT PRESSURE
ULCERS. (CAUSES,
PREVENTION,
ASSESSMENT, EARLY
DETECTION, TREATMENT,
ROLE OF GOOD
NUTRITION, IMPORTANCE
OF TURNING, TURNING
SCHEDULE AND GOOD
HYGIENE.

IF WITH EXISTING
DECUBITUS ULCERS THE
NURSE SHOULD DO THE
FOLLOWING:
1.