NA specific
Documentation
Pressure Injury Prevention
Resources
100
Can NA's initiate preventive measures?
For a Braden scale 18 or less, NAs may apply routine interventions such as Mepilex, Heel boots, Wedges, etc.
100
When should a Braden Scale be completed?
Admission, transfer, qshift & any significant change in patient status
100
How often should the RN/LPN assess skin under preventative Mepilex.
Every 12 hours.
100
How do you access Lippincott?
via the INET, under ALL apps.
200
Can NA’s perform a Braden Score assessment?
No. An assessment is not within their scope of practice
200
When is a 4-eye licensed personnel skin assessment indicated?
Admission
Transfer
Braden of 18 or less
200
True or False: You do not have to use wedges to T&R a patient who is on a bed with the continual lateral rotation option?
FALSE: patients skin still never leaves the bed with the bed turn option. Wedges ensure an appropriate 30 degree turn and offload coccyx when placed correctly.
200
Where can you find the nursing protocol for skin and wound care?
Laminated copy found in each clean supply room. It is also located in Lippincott.
300
When would you use the Medline purple top cream?
As a moisturizing lotion.
300
Who may perform the 4 eye (2 licensed personnel) skin assessment?
RN/LPN, Physician, CRNP
300
Should refusals of preventative measures be documented?
Yes
300
When should you place a wound consult?
For any stage 2 and above pressure injuries, new ostomy patients, and/or guidance on wound/skin care and/or wounds/skin issues not responding to treatment.
400
How do you know whether a patient is at risk for skin injuries/breakdown or not?
Braden Score of 18 or less
400
When should wound photography be completed?
Admission, initial discovery or any significant change in wound/s as previously documented and upon wound nurse consultation
400
Who can document pressure injury prevention interventions in the chart?
RN’s, LPN’s, NA’s
400
If you do not know what pressure injury prevention interventions to implement, where can you find information on this?
Sidebar summary-Braden Scale Interventions link & Lippincott-Pressure Injury Prevention document with PDF image imbedded
500
What color Medline barrier cream would be used for red INTACT skin?
BLUE Silicone barrier cream
(Barrier before breakdown!)
500
Where should you document pressure injury prevention interventions?
Flowsheets; Daily Cares/Safety; Skin Integrity Management section
500
How do you appropriately offload heels with pillows?
Place pillow lengthwise beneath each leg.
500
Where on the INET would you find wound care & pressure injury prevention references?
Lippincott; 2 documents named Pressure Injury & Wound Care Treatment & Pressure Injury Prevention