1. 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

2. 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