algorithm.wocn.org

-- -- Wound, Ostomy, and Continence Nurses Society™ ( ® ) An Evidence-and Consensus-Based Support Surface Algorithm Get Started Funded in part by an unrestricted educational grant from Hillrom Back -- Skin & Pressure Injury Risk Assessment -- An Evidence-and Consensus-Based Support Surface Algorithm Support surfaces are an integral component of pressure injury prevention and treatment, but there is insufficient evidence to guide clinical decision making in this area. In an effort to provide clinical guidance for selecting support surfaces based on individual patient needs, the Wound, Ostomy and Continence Nurses Society (®) set out to develop an evidence- and consensus-based algorithm. To learn more about the algorithm's development, view the accompanying Journal of Wound, Ostomy and Continence Nursing article . The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. -- Tap or click the "Back" button to return to the previous page or step. Tap or click the home icon to return to the beginning. Click the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. Tap or click any number to return to that step in the process. Tap or click the "Full Screen" button to optimize the fit to your device's viewable area. -- RISK ASSESSMENT Initial skin assessment Skin & Pressure Injury Risk Assessment -- A. Non-intact skin/ Not within normal limits: Inflammation MASD Discoloration Induration Bogginess Broken skin Partial thickness Full thickness Healed pressure injury < 12 months B. Intact skin/Within normal limits RISK ASSESSMENT Pressure injury risk assessment Yes, at risk Braden ≤ 18 Not at risk Braden > 18 Learn more about the Braden Scale for Predicting Pressure Sore Risk © RISK ASSESSMENT Pressure injury present? Yes No Trunk/Pelvis Other Location RISK ASSESSMENT Consider Treatment Support Surface Thinking point Supporting information: Review Table A Review Table B Support Surface Product Formulary RISK ASSESSMENT Progress to Treatment Support Surface? Yes No RISK ASSESSMENT Here is your result You have opted not to progress to treatment. Supporting information: Review Table A Review Table B Support Surface Product Formulary RISK ASSESSMENT Pressure injury present? Treat per facility/agency protocol RISK ASSESSMENT Here is your result Skin and pressure injury risk reassessment per facility/agency protocol Test again Supporting information: Review Table A Review Table B Support Surface Product Formulary RISK ASSESSMENT Pressure injury risk assessment Consider patient weight, weight distribution, and the following comorbidities/major risk factors: Advanced age Fever Poor dietary intake of protein Diastolic pressure < 60 mmHg Hemodynamic instability Generalized edema Anemia RISK ASSESSMENT Pressure injury risk assessment Yes, at risk Braden ≤ 18 Not at risk Braden > 18 Learn more about the Braden Scale for Predicting Pressure Sore Risk © PREVENTION Pressure injury risk assessment Preventive Support Surface RISK ASSESSMENT Pressure injury risk assessment Continue using current support surface RISK ASSESSMENT Here is your result Skin and pressure injury risk reassessment per facility/agency protocol Test again Supporting information: Review Table A Review Table B Support Surface Product Formulary PREVENTION Consider Braden subscale scores Choose Support Surface based on: Current patient characteristics and risk factors a-d Previous support surface usage Precautions / Contraindications Refer to Table A: Suggested Support Surface Selections and Table B: Support Surface Precautions & Contraindications Place patient on support surface e Review Table A Review Table B Support Surface Product Formulary Consider patient weight and weight distribution in determining the need for a bariatric mattress and appropriate bedframe. When choosing between a mattress or overlay, consider fall/entrapment risk associated with use of overlays. Consider risk for developing new pressure injuries and history of previous pressure injuries. Consider fall risk in determining the need for a low bed. Ensure that the support surface is functioning properly and used correctly. Minimize the number and type of layers between the patient and the support surface. PREVENTION Skin reassessment per facility/agency protocol Non-intact skin/Not within normal limits: Inflammation MASD Discoloration Induration Bogginess Broken skin Partial thickness Full thickness Healed pressure injury < 12 months Intact skin/within normal limits PREVENTION Pressure injury risk assessment Consider patient weight, weight distribution, and the following comorbidities/major risk factors: Advanced age Fever Poor dietary intake of protein Diastolic pressure < 60 mmHg Hemodynamic instability Generalized edema Anemia PREVENTION Pressure injury risk assessment Yes, at risk Braden ≤ 18 Not at risk Braden > 18 Learn more about the Braden Scale for Predicting Pressure Sore Risk © PREVENTION Pressure injury present? Yes No Trunk/Pelvis Other Location PREVENTION Progress to Treatment Support Surface PREVENTION Pressure injury present? Treat per facility/agency protocol PREVENTION Here is your result Continue using current support surface or consider changing to a different suport surface Test again Supporting information: Review Table A Review Table B Support Surface Product Formulary PREVENTION Pressure injury risk assessment Yes, at risk Braden ≤ 18 Not at risk Braden > 18 Learn more about the Braden Scale for Predicting Pressure Sore Risk © PREVENTION Here is your result Continue using current support surface or consider changing to a different suport surface Test again Supporting information: Review Table A Review Table B Support Surface Product Formulary PREVENTION Here is your result Reassess need for support surface Test again Supporting information: Review Table A Review Table B Support Surface Product Formulary TREATMENT Treatment Support Surface TREATMENT Consider Braden subscale scores Choose Support Surface based on: Current patient characteristics and risk factors f-i Previous support surface usage Precautions / Contraindications Refer to Table A: Suggested Support Surface Selections and Table B : Support Surface Precautions & Contraindications Place patient on support surface j Review Table A Review Table B Support Surface Product Formulary f. Consider weight and weight distribution in determining the need for a bariatric mattress and appropriate bedframe. g. When choosing between a mattress or overlay, consider fall/entrapment risk associated with use of overlays. h. Consider number, severity, and location of existing pressure injuries, as well as risk for developing new pressure injuries and history of previous pressure injuries. i. Consider fall risk in determining the need for a low bed. j. Ensure that the support surface is functioning properly and used correctly. Minimize the number and type of layers between the patient and the support surface. TREATMENT Skin reassessment per facility/agency protocol Non-intact/Pressure injury present Intact/Closed TREATMENT Pressure injury risk assessment Yes, at risk Braden ≤ 18 Not at risk Braden > 18 Learn more about the Braden Scale for Predicting Pressure Sore Risk © TREATMENT Here is your result Continue current Treatment Support Surface or consider changing to a different Support Surface -- Continue current Treatment Support Surface or consider changing to a different Support Surface Test again Supporting information: Review Table A Review Table B Support Surface Product Formulary TREATMENT Pressure injury risk assessment Consider patient weight, weight distribution, and the following comorbidities/major risk fact...