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.