Documentation of Prevention Interventions and
Dressing Changes for PCT3
Categories:
Pressure Injury Prevention
Repositioning
Offloading Heels
Skin Care and Incontinence care
Dressing Change
Flow sheet – Wound Assess/Care (Braden Scores)
1. Pressure Injury Prevention and Intervention – hover over it to see
intervention needed that is documented by the RN. PCT
implements those interventions
2. RN to choose repositioning frequency – every 2 hrs,
or every 2-4 hrs
3. If RN has not documented in the Braden Risk Assessment
Interventions at start of shift, PCT to request an update in order
to have best accuracy
Repositioning – Flow sheet- Go to Daily Care – then to Mobility
1. Scroll down to mobility and document repositioning
2. Document supine, right or left when repositioned. Document
head of bed elevation. Note that Semi fowler position is a supine
position with head of bed between 30 to 45 degrees.
3. Turning frequency chosen by RN – clarify if needed
4. Goal is max 30 degrees for pressure injury prevention. May be
higher for feeding, resp. needs or other reasons.
Heel off-loading Interventions - document
Incontinence Care – go to Flow sheet – Daily Care/Safety - Hygiene
1. Incontinent protective devices
2. Skin care
3. Comfort
Dressing Change - PCT3 receives task from RN for dressing change
After dressing change – PCT3 will document dressing change
1. Go to Avatar and click assess (you are not assessing), scroll down
to treatment. Select type of treatment (cleansed, site care). Select
type of dressing, then document changed and accept.