Pressure
How often should a patient who is at risk for skin intergrity be repositioned?
Every 2 hours, and as needed. If up in chair consider every hour.
Describe the appropriate application of linens on a patient's bed
Single layer of linen- one sheet and one under pad (air permeable disposable chux)
What are two things that can be used to maintain and prevent breakdown of skin folds?
Cleanse with approved barrier wipes for deep creases and/or reddened skin
Use Interdry or body powder
Consult Nutrition, get an order for dietary supplements
Type of pressure relieving device be used in the chair.
Chair Cushion
How should wound drainage be maintained?
Keep wound and tube drainage away from skin with absorptive dressings, and/or skin barriers and/or pouching (i.e., wound management or ostomy pouches).
Tubes should have a method of securement to prevent tension on the tube.
May consult wound nurse for excess drainage
When should an LDA be placed?
when any open area is found, all prior to admission areas should be documented on admission assessment
What should the HOB be set at for a patient who is at risk for skin intergrity breakdown if not contraindicated?
30 degrees or less
Type of boot used to prevent pressure injuries in heels.
TruVue boot
True or False: Incontinent briefs should be taken off while in bed.
True
What needs to be done if any open area is found?
LDA placed, Wound nurse consulted, physician notified, and if found after admission, RL placed.
For Fragile skin, what should be used to remove tape?
Adhesive remover, or alcohol pad.
What type of matress should a patient at risk skin integrity breakdown have?
Waffle mattress, or if air alternating or low air loss, pump should be on at all times.
How do you maintain incontinence and Peri Area Integrumentary?
Check patient with purposeful rounding and repositions to assure that they are clean and dry.
If they are soiled, clean skin with cleansing wipes.
Adult Skin Intergrity Protocol
Give an example of an assistive device that should be used to prevent skin tears.
Gait Belt or ATR Pro.
What prophylactic intervention can be placed on the coccyx to prevent breakdown and how often should it be assessed?
Sacral Mepilex, and should be lifted and examined every shift.
Replace after 3 days or if it becomes saturated greater than 75%.
How often should skin be assessed for dual sign off?
On admission, transfer from another unit, return from surgery or procedure, or with condition changed.
When adding an LDA, what device can be used to place images of the Wound?
Rover Device
This should be increased to maintain adequate hydration, unless contraindicated.
Fluids