Socks Off!
What type of equipment do you need to remove or move to inspect the skin?
ortho devices
O2 / respiratory devices
feeding devices
BP cuff, O2 monitor
catheter
SCDs
ALL CLOTHING
I found a new wound on a patient upon transfer from dialysis. What are my next steps?
1.) Assess wound
2.) Treat wound (cover, clean, etc)
3.) Take ROVER photo, upload to chart
4.) Consult Wound Team
How do I get ahold of the wound care team?
Epic Secure Chat
Page
Place Consult
How many pressure injuries do you think effect patients per year?
2.5million
I can only locate my Wound Champion LNA to help me with my admission's 4eyes skin assessment, can she help me?
No, 2 RNs to perform 4eyes
LNAs may assist in mobilizing the pt for assessment
My patient is nonverbal s/p CVA with left hemiparesis. How should I proceed with their 4eyes skin assessment?
Use alternative communication methods to ask permission
Description of wound: circular area on elbow
Skin Color
Skin Texture
Skin Temperature / Pain
Moisture Level
Skin Integrity
My patient's skin is WDL, no areas of concern are noted. How do I document my assessment?
In the nursing flowsheet >> skin >> 4eyes assessment
In the nursing note using smart phrase .foureyes
A healthcare acquired pressure injury costs approximately what a year for a hospital?
$500-$150K per case
There is an experienced rehab RN working on your unit who has experience staging wounds. Can I have him stage my new pressure injury?
NO
Only the UVMMC Wound RNs are able to stage wounds
My patient who is a 85year-old cow farmer has large calluses on his hands and heels. How do I document these findings in my 4eyes?
Skin intact
No pressure injuries present
Under skin integrity - comment with findings
I am working with my patient for my next 3 shifts in a row. How often should I take a photo and document pressure injury progress?
With any change in condition or treatment to the wound.
The wound team is unavailable to assess wounds daily, uploading photos daily is acceptableMy patient arrived from the ED at 0700 and is scheduled for dialysis at 1200. When do I need to perform a 4eyes assessment?
On admission or transfer
After being off the unit for >3hours
WHO and WHAT is your best resource related to skin injuries, prevention, and treatment on your units?
Your skin champions & your PIP book!
I had a change of shift transfer from the ICU at 1905. Who is responsible for the four eyes skin check? When do I have until to complete it?