Best Dressed
Consults
Braden
Special Situations
Who, What, Where?
100
When should CASP be applied and reapplied?
-When a patients Braden score is 18 or less and then every Monday, Wednesday, Friday
100
When reviewing your orders you see two wound consults in for your patient. What is the problem with this?
Adding a new consult when the patient already has an active consult places the patient at the bottom of the consult list.
100
When is a Braden Score documented?
At admission and once every shift
100
While getting report the off going nurse tells you the ostomy bag started to leak so they reinforced it with silk tape and there has been no drainage since. Was this the correct action by the nurse?
No, if an ostomy bag is leaking it should not be reinforced with tape, the bag should be changed.
100
Does a two-person skin time out have to be completed by two nurses?
No, PCTs can participate in the skin time out with a nurse.
200
Can CASP be placed on open areas of skin? Why or why not?
Yes, CASP can be applied to stage 2 or less pressure injuries.
Refer to the CDH Wound Care Guidelines
200
Your patient currently has a wound consult in for a Braden score of 18 or less. The wound team has not yet seen the patient when you notice that your patient has a new red area that is questionably blanchable on their sacrum. Do you need to put in a new wound consult?
No, modify the current consult order.
200
What score in the nutrition subcategory of the Braden should a nurse place a dietary consult for?
The nurse should place a dietary consult if the patient's nutrition score is 2 or less.
200
What are the steps to renting a specialty bed?
-Place and order for specialty bed in EPIC
-Call Hill Rom and provide information (can be completed by HUC once order is placed):
-Type of bed needed
-Patient name
-Patient room number
-Start date
200
When should two-person skin time outs be completed?
-Within eight hours of admission
-Within two hours of transferring to a new floor
-Within two hours of being off the floor for one hour
300
Who gets CASP?
-Patients with a Braden score of 18 or less
-Patient with two Braden subcategories scores 2 or less
300
The off going nurse tells you that they talked to wound care about the patient but was in a hurry and forgot to mention the purple area on the patient's sacrum. Wound care never came by but placed a note. Why might the wound care not have come to the beside and what should be done now?
The consult may have been in only for a Braden score of 18 or less. For these consults wound care will speak to the nurse, but if the nurse does not mention other concerns preventative practices and recommendations will only occur over the phone. The nurse should reconsult wound care and mention the purple area in the consult.
Additionally, the nurse should get a Rover picture for the wound care team.
300
If the patient has a wound consult in for a Braden of 18 or below, what can the nurse expect?
The WOCN will call the bedside nurse, ask about the patient's skin and if there are any areas of concern or wounds present. If not, a note will be written for recommendations for HAPI Prevention.
300
Where would you go to find out if CDH owns a type of specialty bed or if it has to be rented?
The Specialty Bed and Mattress Rental in Policy Manager.
300
If a patient with a sacral injury has out of bed orders, what can you do to fulfil the order and protect the patients skin?
-Limit sitting sessions to 60 minutes or less
-Position to provide the least amount of pressure to the injury
-Add waffle cushion (unless in ICU)
400
You hear a staff member say they wait till just before CASP is dry to place and OptiView because the tackiness helps the OptiView adhere to the patient skin better. Do you agree with the practice and why?
No, CASP should be completely dry before placing any kind of dressing to decrease the risk of the dressing not adhering or rolling up.
400
After a possible pressure injury is identified what steps must the nurse take?
-Add wound to LDA (not a pressure ulcer)
-Take a Rover photo
-Place a wound/ostomy nurse consult
-Refer to CDH Wound Care Guidelines based on wound assessment until WOCN sees patient
400
When completing the Braden, the nurse is having trouble determining what number to give the patient for sensory perception. What resources does the nurse have to help them make this decision?
When completing the Braden, there is information that can be found to the right side of the flowsheet in EPIC.
400
What are resources you could use when considering a specialty bed for a patient?
-Reaching out to the WOCN
-Reviewing the Specialty Bed and Mattress chart in policy manager
400
What role does the HUC play in the HAPI prevention bundle?
The HUC notifies the Nurse and PCT when the patient arrives to the unit via Vocera.
500
When should CASP be reapplied to patients with OptiView dressings?
Every Monday, Wednesday and Friday.
If the OptiView is intact, CASP should be placed around the OptiView and perineal area if the patient is incontinent of stool or urine
500
A wound consult has been in for over 48 hours, and you feel the wound has gotten worse. What should you do?
Send a Vocera message to the wound care team with your concern. An updated Rover picture would also help the wound care team triage the consults appropriately.
500
Where can you find pressure injury prevention tactics for the Braden Scale?
Tactics can be found on the right side of the flowsheet when completing the Braden.
500
Your patient with an ostomy in bedbound, what action can you take to ease with emptying of the pouch?
Place the bag to the side of the patient to prompt emptying.
500
Why should wedges be used over pillows to turn a patient?
Wedges ensure the patient gets that full 30-degree tilt consistently where pillows cannot. Pillows can be used between the patient's legs and under the elbows.
