Pressure Ulcer Prevention
Do I consult WOCN?
Stump Wrapping
Incontinence Management
Think Outside the Box
100
What interventions should be implemented for any patient with a Braden score of 18 or less?
What is a prophylactic sacral foam, float heels and q2h turns.
100
Patient has scratches to arms.
What is no? Do not consult wound care.
100
This is the preferred method of stump wrapping.
What is a figure-8 technique?
100
For a purewick to be used a patient must meet this criteria.
What is never?
100
An established wound in bleeding through the bandage. This is my first intervention.
What is apply direct pressure for at least 5 minutes?
200
Contact this department for a low air loss mattress.
What is asset management/internal transportation?
200
Patient has a Braden score of 12 but no skin breakdown.
What is yes? Consult wound care.
200
Stump wrapping is appropriate at this point post-operatively.
What is 1 week or per surgeon preference?
200
According to best practice, which patients meet criteria for use of a brief?
What are incontinent patients ambulating with therapy?
200
A wound vac is alarming for an air leak. This is my first intervention.
What is assess the leaking site and apply tegaderm or additional wound vac drape?
300
This is the time frame that you have, per policy, to perform a head to toe skin assessment on all new admissions and transfers.
What is 4 hours upon arrival to the unit? (4 eyes in 4 hours, ie: 2 nurse skin assessment)
300
Patient has a new or worsening wound.
What is yes? Consult wound care.
300
This is the frequency that stump wrapping should be changed.
What is every day?
300
Frequency at which incontinent patients should be monitored on night shift?
What is q2h, hourly rounding, or as needed? (Hourly rounding is q2h from 10pm to 6am)
300
A patient with a wound vac is transferring to SNF and requires continued negative pressure wound therapy but will have no vac for transportation. This is the type of dressing should you apply prior to transportation.
What is a wet to dry dressing?