Page 26 - From Good Sleep to Wellness

OBSERVATION OF TISSUE TOLERANCE
RESIDENT: ___________________________ DATE: _____________

CHECKS
Note position of resident upon entering the room (ie: rt side – back – Lt side)
Has the resident moved since last check? Yes/No
Evidence of redness on bony prominences? (yes/no) & location
If Redness, recheck in 15 minutes Redness still present ? (yes/no)
Other Comments
1 hour
Yes/No
Yes/No
Yes/No
1.25 hours
Yes/No
Yes/No
Yes/No
1.5 hours
Yes/No
Yes/No
Yes/No
1.75 hours
Yes/No
Yes/No
Yes/No
START HERE 2.0 hours
Yes/No
Yes/No
Yes/No
2.25 hours
Yes/No
Yes/No
Yes/No
2.5 hours
Yes/No
Yes/No
Yes/No
2.75 hours
Yes/No
Yes/No
Yes/No
3 hours
Yes/No
Yes/No
Yes/No
GUIDELINE FOR USE
RN RESPONSIBILITIES:
SELECT resident to be assessed and give form to the LPN in charge of the household. May do any shift – may cross over two shifts to complete.
REVIEW the results with the LPN and complete assessment and care planning. Include a sum- mary of the data in RAP summary and discard the data collection form.
LPN RESPONSIBILITIES:
START with a 2 hour check –
NOTE the position of the resident upon entering the room. On following checks, note if the resi- dent has changed position since last check.