PRESSURE ULCERS
STANDARDS OF CARE
SKIN CARE DOCUMENTATION
RESTRAINTS
OTHER
100
Intact skin with non-blanching redness.
What is a stage I pressure ulcer?
100
All patients must have this treatment unless a physician order is written to supersede
What is venous access?
100
the scale used to determine a patients risk for skin breakdown
What is the braden scale?
100
Altered cerebral perfusion, post traumatic brain injury, encephalopathy, alcohol ingestion
What are high risk behavorial paients for restraints?
100
The required PPE to utilize when transporting a patient on contact isolation in their own bed
What is a gown & gloves
200
When polymem has reached this saturation, it should be changed.
What is at 75% saturation?
200
During use, patients will have eye coverage, and position source at least 18 inches away from the patient
What is a heating lamp?
200
The category select when documenting redness in the perineal area due to diahrea
What is the incontinence related category?
200
Must be documented every shift by the RN on the shift assessment portion of the 24 hour flow sheet
What is reassessment of the continued need for restraints?
200
The hand cleansing agent to use when patient is on isolation for an organism that produces spores
What is soap & water?
300
The appropriate treatment plan for a stage II pressure ulcer, with an intact vesicle
What is a vigilon dressing?
300
This part of the pediatric admission assessment on patients< 18 months, & done every week
What is a head circumference?
300
The required charting neessary for all patients with skin breakdown in addition to an assessment
What is a care plan?
300
Require a face to face assessment within one hour of placement and a performed assessment every 15 minutes
What are behavioral restraint requirements?
300
A non-invasive therapy that uses localized negative pressure and a moist wound environment to promote healing
What is a wound vac?
400
Used to cleanse the perineal area of all patients with skin irritation due to incontinence
What is baza cleanse and protect?
400
Used on all drips fo patients > 10 kgs on the colleague pump
What is the guardian feature?
400
The category selection in documenting a non-intact vesicle due to a chemical burn
What is a non-pressure related wound?
400
Should be signed every 24 hours and a different one should be completed if new/different behaviors are noticed
What are the required doctors orders for restraints?
400
This device is used for patients with complications of immobility
What is a KinAir IV bed?
500
The two components for treatment of skin irritation at a J Tube site without fungal overgrowth
What is critic aide and mepilex?
500
Provides qualitative & quantitative data for intubated paients; should be used at all times
What is the ETCO2 reading?
500
Documented when 50% of a meal is eaten by a 4 yr old patient in the nutrition section of the braden scale
What is adequate po intake?
500
RN will receive the worst form of punishment if incomplete when JCAHO surveys
What is a plan of care?
500
These guidelines are folowed for up to 48 hours after receiving the medication
What are cytotoxic waste guidelines?
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