Nursing Care: Delegation & Pressure Ulcers

Delegation of patients should start with the most stable, uncomplicated procedures, and stable diseases.

Avoid delegating patients with Acute, Breathing, and Circulation (ABC) issues.

Preferably, patient delegation should occur for patients past Post-op day 1.

Non-blanchable redness (erythema), superficial, intact skin.

Red/pink ulcer, partial thickness injury of the epidermis & dermis, vulnerable to infection; hydrocolloid dressing necessary.

Yellowish ulcer, full thickness injury of the epidermis, dermis, and deeper tissues (adipose tissue exposed); wet-to-dry dressing.

Ulcer shows bone or muscle; full thickness injury extends deep into tissues; wet-to-dry dressing; consult wound care.

Unable to ascertain underlying tissues due to slough or eschar obscuring the wound bed.

A scale used to assess risk of pressure ulcers, evaluating sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Total Score ≤ 9.

Total Score 10–12.

Total Score 13–14.

Total Score 15–18.

Measures to prevent lung collapse and infection after surgery.

Taking slow, deep breaths to expand the lungs and prevent collapse.

A device that encourages deep breathing by providing visual feedback.

Lung infection linked to ventilator use.

Measures to prevent urinary tract infections (UTIs) and catheter-associated UTIs (CAUTIs).

Measures to prevent infections at the surgical incision site.

Measures to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgery.

Getting patients up and walking as soon as possible after surgery.

Devices that squeeze the legs to improve blood flow and prevent blood clots.

Stocking preventing blood clot formation.

Subcutaneous blood thinners for DVT/PE prevention.

A scale used to assess a patient's risk of developing pressure ulcers.

The likelihood of a patient developing a pressure ulcer due to immobility, poor nutrition, or other factors.

A total Braden score of 12 or less indicates a significant risk of pressure sores..

Proper care for unbroken skin using soap and water.

Care for skin that is broken, injured, or infected, emphasizing infection prevention.

Strategies to reduce the risk of falls in patients.

An assessment tool used to identify individuals at risk of falling.

The spread of infection from one person to another through direct contact.

The transmission of infection from a mother to her child during pregnancy, childbirth, or breastfeeding.

The most important way to prevent the spread of infection.

Infection control measures used for all patients, regardless of suspected or confirmed infection.

Infection control measures used for patients with infections spread by direct contact.

Infection control measures used for patients with infections spread through large droplets expelled during coughing or sneezing.

Infection control measures for patients with infections spread through small particles that remain suspended in the air for prolonged periods.

Grouping patients with similar infections together to control the spread of disease.

Special precautions to prevent infection in patients with a suppressed immune system.

Protective gear worn by healthcare workers to prevent exposure to infectious materials.

Prioritize stable patients with uncomplicated procedures and common, stable diseases for delegation.

Ideal time to delegate patients after surgery, typically one or more days post-operative.

Non-blanchable redness, superficial skin injury in the epidermis layer. (redness that doesn't disappear when pressed).

Red/pink ulcer. Partial thickness skin loss with damage to epidermis and dermis.

Ulcer extends to subcutaneous tissue (adipose tissue). Full thickness skin loss.

Full thickness loss extending to bone or muscle.

Wound obscured by slough (old dead tissue) or eschar (black necrotic tissue); underlying tissue depth can't be assessed.

A dressing that protects the wound by preventing moisture loss & promoting healing. Used for autolytic debridement.

Gauze moistened with saline, placed in the wound bed, then covered with dry gauze; mechanical debridement. This causes discomfort during removal.

Refer complex or severe wounds to specialized wound care professionals for further treatment and management.

Prevent pressure ulcers by turning patients frequently to off-load pressure, avoid massage on bony prominences, use specialty beds or cushions to protect heels, and perform range-of-motion exercises.

Measures to prevent lung collapse and infection after surgery.

Taking slow, deep breaths to expand the lungs and prevent collapse.

A device that encourages deep breathing by providing visual feedback.

Lung infection linked to ventilator use.

Measures to prevent urinary tract infections (UTIs) and catheter-associated UTIs (CAUTIs).

Measures to prevent infections at the surgical incision site.

Measures to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgery.

Getting patients up and walking as soon as possible after surgery.

Devices that squeeze the legs to improve blood flow and prevent blood clots.

Stocking preventing blood clot formation.

Subcutaneous blood thinners for DVT/PE prevention.

Total Braden score of 9 or lower indicates a high risk of pressure ulcers

Total Braden score between 10 and 12 indicates a high risk of pressure ulcers.

Total Braden score between 13 and 14 indicates a moderate risk of pressure ulcers

Total Braden score between 15 and 18 indicates a low risk of pressure ulcers.

Care for unbroken skin using soap and water.

Care for injured or infected skin, focusing on preventing infections.

Strategies to reduce the risk of falls in patients.

Assessment tool to identify patients at risk of falling

Spread of infection between individuals.

Transmission of infection from mother to child.

Essential measure for infection prevention

Infection control measures for all patients.

Infection control for infections spread by direct contact.

Infection control for infections spread via large droplets.

Infection control for infections spread through air.

Grouping patients with similar infections to limit spread.

Special precautions for patients with suppressed immune systems.

Protective gear for healthcare workers to prevent exposure to germs.