GUIDELINES FOR DOCUMENTATION OF WOUND HEALING PROGRESS
WORK
SHEET
Neighbor: __________________________________ Unit: ______________ Age:
_______
Weighted Risk Assessment Braden
Score ___________
Waterlow____________
Pressure Ulcer Risk Factors: (Circle or write where
applicable)
List
Risk Factors Present:
Mobility unable to self-perform difficulty with
ambulation
Hemiparesis contractures Physical restraints:
type_____________________
Altered Level of Consciousness coma altered sensory perception
Incontinence:
urinary
fecal
Nutritional Status:
poor appetite Tube
feeding as primary means of nutrition
Total Protein_____________
Albumin____________
Weight loss: Significant changes in weight (>=5% in 30 days or
>=10% in the previous 180 days)__________________
Significant obesity____________________
Infection
Fever_____________:
WBC ____________ location of
Infection ________________ sepsis
History of pressure Ulcer
Failure of microcirculation:
Hypotension Diabetes
blood
glucose_________
HBGA1C_________
Terminal condition
Cancer
Central nervous system injury
Multiple Sclerosis
Spinal Cord Injury
Ventilator Dependent
head of bed elevated due to medical necessity
Bed rest unable to turn
to specific side r/t SOB
Cerebrovascular disease
Chronic obstructive pulmonary disease
Congestive heart failure
Coronary Artery Disease
Dehydration
Depression
Psychotropic drug use ______________
Drugs that affect healing: _______________
Corticosteroids________________________________
Peripheral vascular disease - Microvascular disease reduces the ability of the arteries and
capillaries to respond to pressure ischemia. diabetes smoking hypertension
Thyroid disease
Renal disease BUN ________________________ Creatnine_________________
Fractures__________________________________
Hemodynamic changes
Low blood pressure <100 <60 ________________________________
Increased blood viscosity and high hematocrit which contribute to tissue damage
Hypovolemia Hgb_____________________ Hct____________________
Impaired healing history
Uremia
Immunocompromised
Bacterial colonization and infection: MRSA_____________ VRE______________ C –
diff___________
Preventive Measures Implemented to Reduce Risks:
Maintain personal hygiene - skin care after incontinence
Try to assure adequate nutrition and hydration: tube feedings assistance with meals health shakes promod
Vit C zinc
Skin Condition Check: __________________ Dry Skin_______________
Evaluate and manage urinary and fecal incontinence: bowel and bladder assessment toileting program
Foley catheter
Seton Health evaluation adult diapers
Position to alleviate pressure over bony prominences and shearing forces over
the heels, elbows, base of
head, and ears.
Try to reposition every two hours when in bed and every hour when in a chair;
if alert and capable, the patient should be taught to shift his or her weight
every 15 minutes while in a chair.
Use appropriate positioning devices and foam padding: pressure relief mattress w/c cushion
Specific turning program
side to side only specific
turning program:______________________________
Pillows Float heels off
bed heel protectors
Maintain the lowest head elevation possible
Use lifting devices: draw sheet trapeze slide board
Try to prevent contractures:
ROM
Restorative OT
Restorative PT
Tube feedings: ___________________ Assistance with feeding: ___________________
Dietician consult as needed: _____________________
Able to cooperate with (or at least not able or willing to obstruct)
treatment:Noncompliance ________________________
Pain issues: Provide pain management: __________________________
Federal regulations require nursing facilities to ensure that a resident who
enters the facility without pressure ulcers does not develop any, unless the
individual's clinical condition demonstrates that pressure ulcer development
was unavoidable.
Wound Treatment:
_______________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Summary of Healing Process:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Revised Plan:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8/6/04
Adapted
from Levine J. The Pressure Sore Case: A Medical Perspective. Elder's Advisor
2000; Vol 2 No 2: 44-50.