Positioning
How often should you reposition a patient?
Every 2 hours
What is the most important nutritional item for wound healing
Protein
How many air permeable pads should be under the patient?
1
Where do you document PIP interventions?
Under Skin Tab on PCS Flow Sheet
When should you apply Sacral Foam dressing?
What do we use to float the heels?
Pillows
When should you consult the registered dietican?
Braden Score 12 or less
Patinent has pressure injury
When do you put an adult incontinent brief on a patient?
Ambulating only
What should you do if patient has old pressure injury LDAs
Assess skin if no longer present remove.
If wounds still present add to flow sheet and consult wound care.
When should you apply barrier cream?
If patient is incontinent
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 High Fall Risk patients
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
When do you perform 4 Eyes Assessnent?
On Admission, Transfer, and shift change if Braden score 16 or less.
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. When should you consult wound care?
IF severe Incontinence Associated Dermatitis (IAD) is present or open wound present
How do you know if patient has been seen by wound care nurse?
Look for wound care consult note and active orders label "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