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SKIN ASSESSMENT/PRESSURE INJURY PROCESS WORKFLOW

Two RN’s complete dual skin assessment within 24 hours of new


patient admissions and patient transfers to the Myelosuppression Unit

Braden Braden
score Primary RN documents skin score
</= 18 assessment, Braden score in EHR > 18

YES
Admitting RN highlights assessment
yellow as significant data and
requests co-sign by 2nd RN
YES

Primary RN to initiate
Pressure Injury
Prevention Protocol

2nd RN co-signs
entire assessment

Pressure NO Complete skin assessment and


injury Braden score per shift on patient
present until discharge or transfer off unit
and document in EHR

YES

Primary RN stages pressure


injury with Skin Champion or
Charge Nurse

Primary RN to initiate
appropriate treatment per stage
and consult Simple Wound

Primary RN to document Plan of


Care and interventions in EHR
per shift
SKIN ASSESSMENT/PRESSURE INJURY PROCESS WORKFLOW 2

References

CPOE Clinical Workflow Analysis. (2009, June 16). Retrieved from

https://mehi.masstech.org/sites/mehi/files/documents/CPOE_Clinical_Workflow_Analysis.pdf

McGonigle, D., & Mastrian, K. (2018). Nursing Informatics and the Foundation of Knowledge. Burlington: Jones

and Bartlett Learning.

Skin and Braden Assessments. (2019). Retrieved from learningexchange.vumc.org:

https://learningexchange.vumc.org/Files/Private/MedOTJ/SkinandBradenAssessments/Content/course.

html?attemptId=600b301c-a063-4928-a968-c0f0c90f8a6a&learnerId=8c260e58-139f-4692-bcb3-

b7b1d5f46802&learnerName=Sherri White

Winters, F. J. (2019). Creating a Simple Flowchart in Microsoft Word. Retrieved from YOUTUBE:

https://www.youtube.com/watch?v=0VR7iBImDB4