NA specific
Documentation
Pressure Injury Prevention
Resources
100

Can NA's initiate preventive measures?  

For a Braden scale 18 or less, NAs may apply routine interventions such as Mepilex, Heel boots, Wedges, etc.

100

When should a Braden Scale be completed?

Admission, transfer, qshift & any significant change in patient status

100

How often should the RN/LPN assess skin under preventative Mepilex. 

Every 12 hours.

100

How do you access Lippincott?

via the INET, under ALL apps.

200

Can NA’s perform a Braden Score assessment?

 No. An assessment is not within their scope of practice 

200

When is a 4-eye licensed personnel skin assessment indicated?

Admission 

Transfer

Braden of 18 or less

200

True or False: You do not have to use wedges to T&R a patient who is on a bed with the continual lateral rotation option?

FALSE: patients skin still never leaves the bed with the bed turn option. Wedges ensure an appropriate 30 degree turn and offload coccyx when placed correctly.

200

Where can you find the nursing protocol for skin and wound care?

Laminated copy found in each clean supply room. It is also located in Lippincott. 

300

When would you use the Medline purple top cream?

As a moisturizing lotion.  

300

Who may perform the 4 eye (2 licensed personnel) skin assessment?

RN/LPN, Physician, CRNP

300

Should refusals of preventative measures be documented?

Yes

300

When should you place a wound consult?

For any stage 2 and above pressure injuries, new ostomy patients, and/or guidance on wound/skin care and/or wounds/skin issues not responding to treatment.

400

How do you know whether a patient is at risk for skin injuries/breakdown or not?

 Braden Score of 18 or less

400

When should wound photography be completed?

Admission, initial discovery or any significant change in wound/s as previously documented and upon wound nurse consultation

400

Who can document pressure injury prevention interventions in the chart?

RN’s, LPN’s, NA’s

400

If you do not know what pressure injury prevention interventions to implement, where can you find information on this?

Sidebar summary-Braden Scale Interventions link & Lippincott-Pressure Injury Prevention document with PDF image imbedded

500

What color Medline barrier cream would be used for red INTACT skin?

BLUE Silicone barrier cream

(Barrier before breakdown!)

500

Where should you document pressure injury prevention interventions?

Flowsheets; Daily Cares/Safety; Skin Integrity Management section

500

How do you appropriately offload heels with pillows?

Place pillow lengthwise beneath each leg.


500

Where on the INET would you find wound care & pressure injury prevention references?

Lippincott; 2 documents named Pressure Injury & Wound Care Treatment & Pressure Injury Prevention

M
e
n
u