SCRMC Patient Safety Module

admission. The “Braden Scale”, a nationally recognized assessment tool, is
used to predict the risk of developing impaired skin integrity. Risk categories
of sensory perception, moisture, activity, mobility, nutrition, and friction and
shear are reviewed and a numerical ranking is given to each area. If the score
is >17, no action is needed. If, however, the score is 15 - 16, the patient is at
mild risk for potential skin breakdown and the Skin Care Standard #32
should be initiated. A score of < 14 indicates moderate to severe risk and a
referral to the Wound-Ostomy-Continence-Nurse (WOCN) is made. For
some patients, even the best of care may not prevent impaired skin integrity,
but preventive measures must be implemented and followed in an effort to
prevent this safety risk.
Skin tears are another form of skin impairment that deserves careful
attention. Many of the elderly and chronically ill have very thin, frail skin
that is easily damaged. Obtain help from another member of the nursing team
to assist in turning, transferring, and toileting these patients. Even the
slightest touch on these patients’ skin can result in a tear, which is considered
a hospital acquired injury. WOCN consult can help both in treatment but
especially in prevention of these types of skin impairments.
The “_______ Scale”, a nationally recognized assessment tool, is used to
predict the risk of developing impaired skin integrity.
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