Prevention Strategies

Gap Analysis

Hospital Acquired Pressure Ulcers

Specific Action(s) / Gap Analysis Questions / Yes / No / If answered question “No”-Identify the Specific Action plan(s) including persons responsible and timeline to complete
Risk Identification
1a) Uses a standard, age appropriate (pediatric vs. adult) tool for skin evaluation and risk assessment.
Asks patient/family permission to photograph skin issues present on admission
1)  Develop skin/risk assessment and reassessment strategy / 1b) Assesses within 4 hours of admission. and daily
1c) Uses visual clues to promote completion of assessment and to identify patients at risk. (Signs on patient's doors, medical record)
1d) Uses a tool to stage pressure ulcers.
2)  Implement Therapeutic and Preventative
Strategies / Therapeutic /Preventive Strategies
2a) Develop an individualized plan care for treatment and prevention of pressure ulcers
2b) Conduct nurse-nurse bedside shift reports for skin assessments with "2 sets of eyes".
2c) Use topical agents that hydrate skin and form moisture barrier, avoiding the use of a thick paste.
2d) Develop a skin care cart with supplies and a guide to managing skin problems based on severity.
2e) Set specific timeframes or create a reminder system (bells, alarms, whiteboard etc) for a patient turning schedule to include offering fluids and assessing for wetness.
2f) Use nursing and unlicensed staff (nurse's aides) for hourly rounding to include the 3 P's Pain/Potty/Position
2g) Keep underpads that dry quickly and wick moisture at bedside in case of incontinence.
2h) Identify a staff nurse on each unit as a skin care resource.
Specific Action(s) / Gap Analysis Questions / Yes / No / If answered question “No”-Identify the Specific Action plan(s) including persons responsible and timeline to complete
2i) Monitor weight, food, fluid intake
2j) Promote hydration and nutrition by allowing patients their preferred foods and liquids and providing supplements
2k) Automated Dietician consult for at-risk patients
3.  Patient and Family Engagement
3a) Fosters a culture that encourages patients and families involvement in plan-of-care.
3b) Allow family, unless contraindicated, to bring in patients preferred food and drink.
3c) Educate family/caregiver on the need for nutrition/hydration including the 3 P's allowing them to assist where appropriate.
3d)
Educate family/caregiver on the prevention and treatment of pressure ulcers at home.