By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

The first 24 hours after a patient’s admission are critical in preventing pressure ulcer development or preventing an existing ulcer from worsening. A skin inspection, risk assessment, and temporary care plan should all be implemented during this time frame. Essentially, it’s the burden of the care setting to prove to insurers, regulators, and attorneys the pressure ulcer was present on admission and interventions were put into place to avoid worsening of the condition. Of course, patients also benefit from having their condition identified and treated promptly.

Taking a close look

Newly admitted patients must undergo a thorough skin inspection within 24 hours of admission. Many times, a wound care nurse is designated to perform this task. Although wound care nurses bring great expertise, their lack of availability can sometimes delay assessment. To avoid delay, all nurses must be capable of completing a skin inspection and accurately documenting their findings. A wound care nurse can educate nurses in skin inspection and documenting skin concerns.

Assessing risk and planning care

Performing a risk assessment within the first 24 hours ensures interventions are put in place to prevent skin breakdown and promote healing. That’s done as part of developing a temporary care plan. The care plan should contain interventions designed to minimize, stabilize, or remove identified risk factors. The interventions need to be put in place as soon after admission as possible.

Whenever possible, try to identify risk factors and/or wounds before the patient’s admission to ensure interventions are in place before the patient arrives.

Even if the care setting allows several days to complete a care plan, a temporary care plan for prevention of skin breakdown is strongly recommended within the first 24 hours. At a minimum, the temporary care plan should address the following:

• support surface for the bed and the wheelchair/sitting surface
• individualized turning and repositioning schedules for patients and helping patients to be as mobile and active as possible
• incontinence management, if needed
• keeping the skin clean and dry
• keeping the heels elevated off the bed
• addressing nutritional/hydration concerns for wound healing, dietary referral
• referrals to therapy, as appropriate
• daily inspection of the skin by nonlicensed staff and weekly skin inspections by licensed staff
• risk assessment per policy.
If the patient has a wound, the temporary care plan should also include:
• applying topical treatment, as ordered
• monitoring the patient for signs and symptoms of infection
• reporting any decline or changes to the primary care provider and family designee
• completing a comprehensive assessment of the wound at least weekly.

If nurses are uncomfortable with developing a care plan based on the risk assessment, it might be helpful for a manager or wound care expert to develop a “cheat sheet” with potential interventions that correlate with the individual risk factors identified. Once the temporary care plan is developed, it should be communicated to the nurses, nursing assistants, and and others on the interdisciplinary team.

Meeting your goal

Your goal as a clinician is to prevent the development of a pressure ulcer and ensure proper interventions are in place to promote healing in pressure ulcers present on admission. If you complete a skin assessment and risk inspection and then develop and communicate a care plan within the first 24 hours of admission, you should be successful in achieving that goal.

Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has been specializing in wound prevention and management since 1990.

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