RN Tissue Trauma Education

Transcription

1 RN Tissue Trauma Education Phase II Education The Templates Juanda Alston, RN, BSN, MBA Nurse Educator / Consultant Ext /14

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3 What You Will Learn

4 The Complete Skin Assessment vs The Complete Skin Inspection

5 The Complete Skin Assessment

6 The Complete Skin Inspection Performed daily, usually when providing care. Can be performed by RN s, LPN s, Nursing Assistants or Health Techs. It identifies alterations in skin integrity, i.e. rashes, skin tears, neuropathic, arterial, venous ulcers, etc. It also includes careful observation of all pressure points, monitoring for redness and potential breakdown. It is also important to look for any signs of deep tissue injury, (DTI), and pressure ulcers.

7 Understanding The Process Determining Risk Documentation & The Templates

8 There are various templates that are related to the documentation of Tissue Trauma: The Nursing Skin Assessment The Nursing Skin Assessment- Supplement (new) The Nursing Skin Reassessment The Nursing Skin Reassessment- Supplement (new) The Tissue Trauma Report (revised) The Tissue Trauma Treatment Note (new) The Tissue Trauma Report Worksheet (revised for GEC, new for other areas) Please Note: No changes have been made to the Nursing Skin Assessment and Re-assessment, so an example is not presented in this PowerPoint, (see Attachment F & H of the policy).

9 Determining Risk

10 Nursing Skin Assessment & Reassessment These templates are not included in this educational module because all RN s have been trained on their use and no issues have been identified with the completion of these templates. *If you need re-education please see your Unit Based Educator or Nursing Education.

11 Nursing Skin Assessment

12 Nursing Skin Assessment- Supplement

13 Nursing Skin Assessment- Supplement

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16 Nursing Skin Assessment- Supplement Don t forget to add the Attending Provider / Primary Care Provider /PA/NP as an additional signer of this note.

17 Nursing Skin Re-Assessment & Nursing Re-Assessment- Supplement

18 Nursing Skin Re-Assessment- Supplement

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21 Tissue Trauma Report

22 Tissue Trauma Report

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28 Tissue Trauma Worksheet

29 Tissue Trauma Worksheet Located on the Unit s Share Drive. To be completed by the RN or LPN that completed the Tissue Trauma Report during wound rounds. The information on this worksheet directly comes from the most current Tissue Trauma Report. It is important that the information on this worksheet is up to date and accurate. This worksheet will be used by your Line of Service QI Coordinator for various reports. An example of reports that must be completed includes but not limited to: Tissue Trauma Council; Line of Service Executive Committee; ACOMB; VISN; and Central Office.

30 TISSUE TRAUMA REPORT WORKSHEET Patient's Name Initial & Last Four Unit/ Area Room # Adm Date Last Skin Skin Reassessment Assessment (week from adm/transfer) Braden Score Date Date of Tissue Trauma Type of Tissue Trauma Stage if Pressure Ulcer

31 Continued Documentation

32 Documentation How to document daily, twice a day or three times a day tissue trauma care? A note must be written. RN s and LPN s are required to document the care provided. Until the new Tissue Trauma Treatment Note is available in CPRS, please use the Note Title: Nurses Note Begin your note with.. Wound Care: Then add your information

33 Tidbit Information

34 The Documentation Process Re-Cap Nursing Skin Assessment & Nursing Skin Assessment Supplement Completed by the RN in CPRS when there is a new admission, transfer, discharge, or change in status. Nursing Skin Re-assessment & Nursing Skin Re-assessment Supplement Completed by the RN, in CPRS, minimally weekly when the weekly skin assessment occurs. Tissue Trauma Report When tissue trauma exist Completed, (after care has been performed), by the RN or LPN on Admission, Transfer, Discharge, Change of Status, and weekly during wound care rounds.

35 The Documentation Process Re-Cap Tissue Trauma Worksheet Located on the Unit s Share Drive Completed by the RN or LPN that completed the Tissue Trauma Report during Tissue Trauma Rounds.

36 Coming Soon Tissue Trauma Treatment Note This Template will be used for the documentation of Tissue Trauma care that has been performed.

37 Putting It All Together

38 Putting It All Together Assessment, observation, reassessment, documentation of Tissue Trauma care and appropriate interventions are most important for our veterans. This can prevent a small problem from developing into a large problem. Once Tissue Trauma is documented it is the responsibility of the Unit/Area Based Tissue Trauma Team to round weekly and document onto the Tissue Trauma Report. See Policy PCS-69, for clarification of the roles and responsibilities of the Tissue Trauma Nurse and the Tissue Trauma Unit Based Team in your area. Any Nurse that performs Tissue Trauma Care Must Document the care that was performed.

39 Putting It All Together Always think ahead Continuum of Care. Will the veteran need supplies for home? Can they or a family member perform the care? What type of patient education is needed? We want to make sure they have the right supplies and the right training before they leave the outpatient clinic, or is discharged to home from an inpatient unit. Don t be afraid to consider alternate products or treatments if the wound is not healing as planned.

40 What s Next?

41 Coming Soon: Tissue Trauma Treatment Note This Template will be used for the documentation of Tissue Trauma care that has been performed, and will take the place of the Wound Treatment Note. Reminder: Until the template is available use the Note Title: Nurses Note Begin your note with.. Wound Care: Then add your information *Remember, if it is not documented it wasn t done.

42 What s Next? The following education and/or information will be provided in the future: How to perform a proper skin assessment. Proper identification of various types of tissue Trauma. Information on the various wound care products available. The best product to use for various types of Tissue Trauma. Competency. Every Clinician that performs, observes, assesses, and/or writes orders for wound care, must demonstrate competency.

43 Resources Once you have completed the assigned education in TMS, you may review this PowerPoint on the CVAMC intranet. For a limited time, this Educational Module will be located on the following SharePoint Site, under the Specialized Training tab: You will need to be in slide show mode in order to activate this hyperlink. If you are unable to activate it, please type into your browser and it will take you to the SharePoint site. Medical Resource Education Site If you have any questions please see your: Wound Care Certified Clinician Tissue Trauma Nurse Unit Based Educator OR Juanda Alston Nurse Educator, Ext Tissue Trauma Policy PCS-69