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:

__________________________________________________________________________

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8/6/04

Adapted from Levine J. The Pressure Sore Case: A Medical Perspective. Elder's Advisor 2000; Vol 2 No 2: 44-50.