Page 25 - From Good Sleep to Wellness

1. The RN will determine the need for periodic observations of tissue tolerance and will give the tool to the LPN/TMA in the household. May be conducted on any shift – may cross over two shifts to complete as needed. May want to consider based upon the indi- vidual resident’s needs if there are times of the day with the concern is greater.
2. The LPN starts with a 2-hour check. Note the position of the resident upon entering the room. On following checks, note if the resident has changed position independently since last check. Check bony prominences for redness. If find evidence of redness – note the location in the space provided.
3. If there is evidence of redness: recheck the areas in 15 minutes and note if the red- ness is still present. If no, proceed to the 2.25 hour check. If yes, proceed to 1/75 hour check.
4. Increase/decrease the time span between checks until you reach the point where there is redness and it does not disappear in 15 minutes.
5. Review results of observations with the RNCC.
6. The RNCC will consider the results of the observations when determining the residents individualized toileting and repositioning schedule. Results of the observations will be documented in the RAP summary note.
7. The Braden Scale is completed on admission, annually & reviewed no less than quarter- ly and/or with significant change. The RN will decide whether or not the evaluation of tissue tolerance is needed based upon the knowledge of the individual resident’s needs.