Skin Integrity

Braden scale assessment, pressure injury prevention, and wound monitoring

Sushila Mehta (ICU-3) — Braden 9 (Very High risk). Grade III sacral pressure injury. NPWT in situ. 2-hourly repositioning MANDATORY. Document on tilt chart.

Sushila Mehta, 82F — ICU-3

Braden Score: 9

Very High Risk

Skin Status: Grade III pressure ulcer — sacrum (6.2 × 4.8 cm). NPWT in situ. Right heel — Grade I erythema (non-blanching). Both ears — pressure redness from oxygen mask.

Repositioning: Every 2 hours — nursing tilt chart initiated. L side, R side, supine rotation.

Equipment: Alternating pressure mattress. Heel protectors bilateral. Silicone foam dressings.

Nutritional support (albumin 2.8 — dietitian review). NPWT sacrum continued. Daily photo documentation. Wound care nurse review tomorrow.

Rajan Mehta, 75M — ICU-1

Braden Score: 12

High Risk

Skin Status: Skin intact. IV site right forearm — 1+ erythema (phlebitis Grade 1). Ear pressure redness from Ventimask — silicone pad applied.

Repositioning: Every 2 hours when haemodynamically stable. Patient does not tolerate full repositioning — small shifts only.

Equipment: Pressure-redistributing mattress. Pressure relief heel boots.

IV site re-sited to left forearm. Continue positioning schedule. Daily Braden reassessment. Protect occiput from ventilator circuit pressure.

Gopal Mehta, 45M — GW2-3

Braden Score: 17

Mild Risk

Skin Status: Skin intact. Surgical wound abdomen — clean, dry, intact dressing.

Repositioning: Self-repositions. Advised to mobilise.

Equipment: Standard mattress — no special equipment required.

Routine wound dressing change day 3. Ambulate BD.