HAPI Assessment

Kyle Michaels is a 55 y.o. male with history of type II Diabetes Mellitus, Hypertension, Hyperlipidemia, Coronary Artery Disease, and Diabetic Foot ulcer, presents to the emergency department with chief complaint of worsening sacral ulcer. Patient resides at home and was receiving home health wound care and eventually progressed into needing IV antibiotics and was suggested to go to the ED for worsening infection.

Inpatient Hospital Room

1. Accurately assess at-risk patients using a validated risk assessment tool (e.g., Braden Scale).
2. Identify early signs and stages of pressure injuries.
3. Implement evidence-based prevention strategies (e.g., turning schedules, moisture management, nutritional support).
4. Document pressure injury assessments and interventions according to hospital policy.
5. Communicate findings effectively to the healthcare team to initiate timely interventions.

1. Use the Braden Scale or institutional equivalent to evaluate risk factors for pressure injury.
2. Distinguish between Stage 1–4 pressure injuries, deep tissue injury, and unstageable wounds.
3. Select and initiate appropriate skin care and repositioning protocols based on patient needs and hospital protocols.
4. Escalate findings to wound care or charge nurse per policy.
5. Accurately document assessment findings and interventions in the electronic health record (EHR).