Positioning
How often should you reposition a patient?
Every 2 hours
What is the most important nutrient for wound healing?
Protein
How many air permeable pads should be under the patient?
1
Where do you document PIP interventions?
Under Skin Interventions on PCS Flow Sheet or PCT/CNA Flow Sheet
When should you apply Sacral Foam dressing for Pressure Injury Prevention?
Braden score 18 or less
What do we use to float the heels?
Pillows
When should you consult the registered dietician?
Braden Score </= 12 or less
OR
Has a Pressure Injury
When do you put an adult incontinent brief on a patient?
Ambulating only
On Admission assessment, you identify the patient has a purple, maroon discoloration over their right lateral ankle. What documentation intervention should you do?
Enter LDA
Offload / Float area
Consult Wound Care
Nursing Assistant - notify primary nurse
When do you perform 4 Eyes Assessnent?
On Admission, Transfer, and shift change if Braden score 16 or less.
In critical care: every shift
30 degrees or less
DOCUMENT if contraindicated or patient refusal
What is the amino acid supplement that promotes wound healing?
When should external catheters be used?
Bed Bound
OR
Patient has a Sacral Wound
What do you document if patient refuses PIP
Document refusal using SMARTPHRASE
.PIPrefusal
You notice a new purple discoloration on a patient's heel, what should you do?
Float heel
Apply Heel Foam Dressing
Consult Wound Care Team
What bed should we use in high risk patients?
Alternating Low Air Loss
What is the name of the suppmement that helps with diarrhea?
Banatrol
How many times should you fold the draw sheet?
Once
True or False: When repositioning your patient, it is only necessary to document turn once a shift on the flow sheet?
FALSE
document actual position every 2 hours: Right, Left or Supine
NO - Heels must be floated off of the mattress and pass the hand test. You can roll the pillow edges or add a blanket under pillow to ensure the heels are NOT touching the mattress.
Your patient has a wound on their sacrum, where should you put the pillows to reposition patient side-lying?
Above the Sacrum & Below the Buttocks
Your patient is receiving tube feeds through a NG tube and you notice a purple discoloration to their nare. What should you do?
Move tube off of discoloration if possible.
Consult wound care nurse.
Your patient has had multiple bowel movements and now their buttocks are very red. Name one intervention you can implement.
Clear Barrier Zinc Ointment
Limit Layers of Linen
Use Air Permeable Incontinent Pad
Avoid adult incontinent briefs
How do you know if patient has been seen by the wound care nurse?
Look for wound care consult note and active orders labeled "Wound Dressing"
Your patient has a wound vac dressing on the coccyx. The machine is not alarming. When should you turn the patient to look at the wound vac dressing?
Every 2 hours