Page 24 - From Good Sleep to Wellness

Sample Guideline for Tissue Tolerance
Department: Long Term Care
TOPIC: Guideline for Observation of Tissue Tolerance

Policy: Tissue tolerance will be considered, along with the results of the Braden Skin Assess- ment, when developing an individualize care plan for residents with regard to B&B and position- ing requirements. Residents will be allowed to awaken naturally at night for cares whenever possible to maximum the number of hours of uninterrupted sleep unless more frequent toileting and/or positioning is indicated.
(see P&P “Waiving q2h toileting and positioning requirements” for details about care planning an individualized plan that is less than the q2h requirement.)
Purpose: To assist RN staff in the determination of resident’s ability to tolerate pressure on bony prominences.
NATURE OF THE FORM
The Tissue Tolerance form is a data gathering tool only. It is used to guide the recording period- ic observations. Once conclusions have been made and documented by the RN in the RAP summary, the form is discarded.
OPERATIONAL DEFINITIONS
Evaluation of Tissue Tolerance – it is understood that there is no scientific method available for determining tissue tolerance. The process outlined on this form is a guide for recording periodic nursing observation related to the resident’s skin response to pressure over given time periods.
RESPONSIBILITY:
The RNCC will determine the need to conduct periodic observations of tissue tolerance in con- junction with the Braden Skin assessment and documenting results in MR.
The LPN/TMA in the household where the resident lives will be responsible for making periodic observations and recording results on the form.
PLACEMENT IN THE MEDICAL RECORD
This form is used for gathering data only. It is not a part of the medical record and may be dis- carded once the observations have been summarized in the MR.

Procedure:
(follow guideline for use on the form)
Approved By:
M Oelfke Sr. Director LTC
Written By:
M Oelfke Sr. Director LTC
Original Date:
8/06
Effective Date:
8/06
Review Date:
10/11
Revised Date:
11/10