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CompetencyTopic: Pressure Ulcer Prevention and StagingObjective: Method of Evaluation Key:O = ObservationRD = Return DemonstrationT = TestV = VerbalCompetency Criteria Method of EvaluationMetNot MetKnowledge:List the most common locations pressure injuries occurUnderstands the contributing factors that can lead to pressure injuryList different strategies to prevent pressure ulcersExplain the use of the Braden scale and each of the different assessment categoriesList when skin assessment must be completedSkills:Perform hand hygiene and don personal protective equipment if indicatedEstablish privacyIntroduce self and explain procedure Raise the height of the bed access the wound site while ensuring maximum privacyVisually inspect the Pressure injury and surrounding skinDescribe the injury If the wound is covered by slough or eschar, describe the material covering the wound baseIf the injury is local, discolored tissue, describe the nature and color of the tissuePalpate intact skin, noting temperature, edema, bogginess or induration, and if erythema is blanchablePerform a blanch test to evaluate for reduced circulationPress on pink, red, or darkened skin until the area blanches or lightens in colorRemove the pressure and the area should return to the original color within a few seconds indicating acceptable circulation (Note that if the area remains light in color, blood flow is impaired and tissue damage is probable)Note patient report of pain, tenderness, itching, or other discomfort during skin assessmentMeasure the size of wound and, if full thickness skin loss is noted, measures the depth of tissue damageMeasure the length and width of the wound using the measuring toolMoisten a sterile swab with normal saline and insert it into the wound at a 90° angle until the tip touches the base of the woundMark the point on the swab that is level with the wound surface or grasp the swab between the thumb and forefinger at the point where it is even with the skin surfaceRemove the swab and measure the distance the device was inserted against the measuring tool to determine the depth Measure wound depth in other locations if different throughout wound bedInsert the swab into any areas of tunneling or underminingRemove the swab and measures the distance the device was inserted against the measuring tool to determine the depth of any tunneling or underminingNote the direction tunneling or underminingPhotograph the wound by facility protocol.Identify the stage of the pressure injuryDispose of used materialsRemove PPE and perform hand hygieneCreate LDA for pressure injury and place an IRISConsult wound specialist as necessary and notify physician for treatment ordersOff load pressure to areaAttitude:Values the importance of pressure injury prevention for the patient and organizationSupports the prevention of pressure injuries by consistently adhering to the pressure injury prevention program measuresEncourages patients to reposition while in bed or sitting in a chairComments: References:Policy # 12048Nursing Resource Center PlusForms of evidence that may be submitted to demonstrate competency: Return demonstration during annual skills validation HCL CE completion with passing test score Employee’s SignatureEmployee NumberDate Validator’s SignatureEmployee NumberDate ................
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