Wound Care Certificate Day 1/8- Lesson 1A: Skin Health

Please watch the following recorded lecture and respond to the discussion question below.

Introduction
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Lesson 1A: Skin Health
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What risk assessment tools are used in your organization?

Instructions: You must post your responses in the comments section below before the  live lesson on Day 1. The instructor will review your comments and have a debrief discussion at the start of the next live session. The comments section will not be moderated otherwise.

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12 comments on “Wound Care Certificate Day 1/8- Lesson 1A: Skin Health

  1. Inter RAI PURS score, Braden Scale has been used in the past at our facility, Falls risk with MORSE code, monthly head to toe assessments, PSWs notify registered staff of any changes in skin condition

  2. Assessment tools we use:
    Admission: Head to toe within 24 hrs, quarterly and post fall
    Weekly skin assessments for Treatment creams use and effectiveness.
    Braden scale
    Nutrition consultant to inform of eating issues, weight assessments
    Monitor food and fluid intake, issues with self feeding or requiring assistance.
    RAI - Pressure ulcer Scale,
    Cognitive assessment
    Fall risk assessment
    PSW's notify nursing of any marks or changes on residents body.
    Nurses visual observation

  3. Admission, re-admission and quarterly assessments - Braden Scale, PURS assessment.

    Weekly assessment as per the LTC Act/Reg.

  4. Braden scale
    Nutrition assessments
    Head to Toe admission assessment
    Weekly skin assessment
    Review diagnosis
    PSW patient daily overview during care

  5. Braden Scale for risk assessment
    Head -to-toe assessment upon admission or readmission (return from hospital)
    Weekly skin assessments ( Skin tear, surgical site, Ulcers, Bruise/hematoma, and rash/other (everything else). Assessments are audited
    PSW's document daily skin checks
    Nutrition assessments

  6. These are done upon admission and at least every shift or as often as needed:
    1.Braden Scale
    2. Overall head-to-toe assessment (includes brief interview with the pt)---with the inclusion of patient's cognitive ability to assess pt's capacity to benefit from health teachings, nutrition, current medication review

  7. -Braden Pressure Ulcer Risk Assessment Tool- updated yearly and additionally if health status change
    -Clients have daily tub baths or showers with skin assessments completed at this time

  8. - Braden scale- assesses sensory perception, nutrition, continence, activity and mobility
    - Norton scale- assesses overall condition, activity level, cognition, and continence
    - daily skin assessment to check for changes or new wounds

  9. - Braden Pressure Ulcer Risk Assessment Tool

    - RAI Pressure Ulcer Risk Scale (PURS) - outcome scoring reviewed quarterly and/or if significant change in status

    - Implement weekly wound assessments for registered staff to complete if warranted

  10. -InterRAI PURS Score is being used to determine the risk of skin impairment among residents. This higher the score is, the higher is the risk of skin impairment.
    -Braden Scale assessment (in wound rounds app)on admission/readmission to determine the risks of pressure injuries. This basically assess the sensory perception, moisture, activity, mobility, nutrition and friction/shear.

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