Sbar: Skin Care Instructions Template
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1SBAR: Skin Care Instructions
S
Situation
Resident Name: ______________________________________________________ Age:___________ Admit Date: _________________
Admitting physician/consulting physician: ___________________________________________________________________________
Diagnosis/reason for admission: ____________________________________________________________________________________
Treatment plan: _________________________________________________________________________________________________
B
Background (check all that apply)
Past medical history: _____________________________________________________________________________________________
Allergies: _______________________________________________________________________________________________________
q
q
q
q
Diet type: ___________________________________________
NG/G-tube feedings
TPN/PPN
Ostomy/drains
Foley
Medication
Medication
A
Assessment (check all that apply)
q
q
q
q
q
Pressure ulcer present
Precautions:___________
Completely immobile
Limited mobility
Fully mobile
q
q
q
q
q
q
Incontinent
Impaired sensation
Alert/oriented
Confused
Lethargic/unresponsive
Photos taken
Braden Score:_______
Decubitus Key
Site Diagram
q
High Risk
Stage I: Red/skin intact
Front
Back
q
Low Risk
Stage II: Superficial breakdown
q
Stage III: Skin breakdown Sub Q involved
No Risk
Stage IV: Skin breakdown. Muscle/bone exposed
Right
Left
Left
Right
*Do no stage if base of wound not visible
Date
Site #
Stage
Size (in cm)
Description (color, drainage, odor, sloughing, eschar, undermining)
R
Recommendation (check all that apply)
Pressure Ulcer Prevention Measures
Pressure Ulcer Management
q
q
q
Keep clean and dry
Avoid diaper/brief use
Ulcer treatment: _____________________________________
q
q
Apply cleanser/barrier lotions to ________ every ____ hours
Dressings (specify type and frequency): __________________
q
Apply Nystatin powder to _____________ every ____ hours
___________________________________________________
q
q
Use special bed/mattress (specify type): __________________
Wound vac: _________________________________________
q
q
Turn and reposition patient every ______ hours
Consider Foley catheter: _______________________________
q
q
Use chair cushion (specify type): ________________________
Odor control: ________________________________________
q
q
q
Elevate heels
Use heel protectors/heel lift
Dietary/nutrition consult
q
q
q
Use elbow protectors
Dietary/nutrition consult
Other:______________________________________________
q
Other:______________________________________________
___________________________________________________
Comments: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Assessment and recommendations completed by (signature) __________________________________
Date: __________________
Treatment protocol approved by (signature) ________________________________________________
Date: __________________
Document available at
MO-08-52-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
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