Order Set
Patient admitted to the hospital and has a Braden scale of 18 or less.
What is Pressure Injury Prevention Order Set?
A patient is being admitted from the ED or another unit and a skin assessment is being performed. This is documented at least 1 minute after the admission assessment.
What is a 2nd RN Skin Check?
A complete skin assessment is required to be documented...
What is upon admission and every shift?
A patient has a Braden Scale of 18 or less and/or has a current wound. This must be done every 2 hours.
What is turning the patient?
Patient is found to have skin damage that could be attributed to moisture.
What is the Moisture Associated Skin Damage Order Set?
A patient is being admitted from the ED or another unit and a skin assessment is being performed. This task must be done for a complete skin assessment.
What is the removal of all dressings and/or devices depending on orders?
Preventive dressings are applied to the patient and can remain on the patient for 3 days per the order set. The patient's skin is being assessed. This action must be done for a complete skin assessment.
What is taking a peek under all preventive dressings and replacing as needed?
Your patient is needing to be turned every 2 hours per skin assessment findings. This responsibility falls on..
What is the Primary RN?
A skin tear is assessed on a patient.
What is the Skin Tear Order Set?
A patient is being admitted from the ED or another unit and a skin assessment is being performed. An open wound is found and this should be added to the patient's chart.
What is an LDA?
A patient has wounds that are known and have previously been documented. This task must be performed every Wednesday.
What is new pictures to be taken?
Q2 turning is a requirement for all patients with a Braden scale of 18 or less. This preassigned task can be found..
What is at the nursing station on the turning form?
A stage 1, 2, or DTI pressure injury is assessed.
What is the Stage 1,2, & DTI Order Set?
A patient is being admitted from the ED or another unit and a skin assessment is being performed. An open wound is found and this should be added to the patient's chart with the LDA charting.
What is a picture and applicable wound measurements?
Your patient has just been turned and charting is being documented. This must be included in the documentation.
What is the position the patient has been turned to?
You have noticed that your turn is coming up for Turn Teams but you are needed elsewhere for patient care. This must be done prior to your turning hour.
What is communication with the charge nurse or another staff member to ensure your turn is being completed?
A stage 3, 4, or Unstageable pressure injury is assessed.
What is Stage 3, 4, or Unstageable pressure injury order set?
A patient is being admitted from the ED or another unit and a skin assessment is being performed. A wound was found, appropriate wound order set ordered and appropriate charting has been completed. This consult should also be ordered.
What is a wound care nurse consult?
A patient has a respiratory and/or surgical device and a skin assessment is being performed. This must be done for a complete, accurate skin assessment.
What is device removal/lifting as allowed per MD orders?
A patient is refusing to be turned despite education given. This person should then be notified.
What is the Charge RN and Leadership as needed?