CMC Skin Integrity Bundle Skin Assessment Within 4 Hours Of Admission And Transfer And Upon Discharge To SNF Or Rehab Assess Risk Use Braden Scale Consider Alternative Risk Factors Vigilant Monitoring Around & Under Medical Devices Apply Protective Barriers When Appropriate Alleviate Pressure Early Mobility Promote Physical Activity Use BMAT Surface Selection Select & Apply Appropriate Surface Waffle Mattress/Seat, Low Air Loss Mattress Keep Turning Reposition At Least Every Two Hours Use Pillows And/or Other Devices To Alleviate Pressure Incontinence Management Use Absorbent Pads & Barrier Creams To Minimize Moisture Provide Routine Pericare Keep Skin Clean And Dry Nutrition/ Hydration Promote Oral/ Nutritional Intake A V E S K I N

Braden Risk Assessment Scale 4. NO IMPAIRMENT Responds to verbal commands and feels and voices discomfort. 3. SLIGHTLY LIMITED Responds to verbal commands but can’t always communicate discomfort. 2. VERY LIMITED Responds only to painful stimuli. 1. COMPLETELY LIMITED Unresponsive. Doesn’t moan/groan/flinch to discomfort. 4. RARELY MOIST Skin is usually dry. 3. OCCASIONALLY MOIST Skin is occasionally moist. 2. OFTEN MOIST Skin is often moist. 1. CONSTANTLY MOIST Skin is kept moist almost constantly. 4. WALKS FREQUENTLY Walks frequently within room and at least twice per day outside room. 3. WALKS OCCASIONALLY Walks occasionally in very short distances. 2. CHAIRFAST Ability to walk severely limited or nonexistent. 1. BEDBOUND Confined to bed. 4. NO LIMITATION Makes major and frequent changes in position without assistance. Makes frequent though slight changes in body or extremity position. Makes occasional slight changes in body or extremity position. 1. COMPLETELY IMMOBILE Does not make even slight changes in body position. 4. EXCELLENT Eats most of every meal. 3. ADEQUATE Eats over half of most meals. 2. PROBABLY INADEQUATE Rarely eats a complete meal. 1. VERY POOR Never eats a complete meal. 3. NO APPARENT PROBLEM Has sufficient muscle strength to lift up body when moving in bed. 2. POTENTIAL PROBLEM During move skin slides to some extent. 1. PROBLEM Skin slides during all movement with frequent sliding down in bed. SENSORY PERCEPTION FRICTION SHEAR MOISTURE ACTIVITY MOBILITY NUTRITION NONE MILD MOD HIGH SEVERE RISK SCALE 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6