Page 293 - CHHA Binder 2.3.20

2/2/2020

The Skin Assessment / Pressure Ulcers

Incorporate your skin assessment and Braden scoring as
part of the functional assessment activities on the
SOC

 Is there a risk for friction / shear injury when
transferring from bed to chair?
 Can the patient turn from side to side?
 Ask the patient if they have had pressure ulcers or
if their heels or other boney prominences are sore
or numb - this can be evidence of stage 1 ulcer
especially if it is difficult to visualize
 Look/Touch/Ask Questions
 Check the patients feet/ toes thoroughly

Assess and Document

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