Docstoc

Wound Assessment and Management Tool

Document Sample
Wound Assessment and Management Tool Powered By Docstoc
					                                                                                                                           (Affix patient label here)                                                                                                                                                                                                              (Affix patient label here)
                                                                                              URN:
                                                                                                                                                                                                                                                                                                                                          URN:
                                                                                              Family Name:
                                                                                                                                                                                                                                                                                                                                          Family Name:

                                         WOUND ASSESSMENT AND
                                                                                              Given Names:
                                                                                                                                                                                                                                                                    WOUND ASSESSMENT                                                      Given Names:
                                           MANAGEMENT TOOL                                    Date of Birth:                           Sex:        M       F                                                                                                         AND MANAGEMENT
                                                                                                                                                                                                                                                        The Townsville Hospital                                                           Date of Birth:                              Sex:       M             F
                                    The Townsville Hospital
                                          ASSESSMENT REQUIRED ONCE PER DAY ONLY, OR AT NEXT DRESSING ACCORDING TO FREQUENCY REGIME                                                                                                                      DATE:
                                                                                                                                                                                                                                                        REFERRAL SOURCE:
                                   DRESSING DATE & TIME                       DRESSING DATE & TIME                              DRESSING DATE & TIME
                                                                                                                                                                                                                                                        UNIT / PRACTICE:
                                   WOUND SITE                                 WOUND SITE                                        WOUND SITE                                                                                                                                           MEDICAL HISTORY
                                   FREQUENCY REGIMEN                          FREQUENCY REGIMEN                                 FREQUENCY REGIMEN                                                                                                       DIABETES
                                  ANTIBIOTICS                                 ANTIBIOTICS                                      ANTIBIOTICS                                                                                                              RHEUMATOID ARTHRITIS
                                    Yes →        Oral             IV            Yes →         Oral             IV                Yes →            Oral         IV                                                                                       MOTOR / SENSORY DEFICIT
                                    No           Ceased                         No            Ceased                             No               Ceased                                                                                                CANCER
                                   INVESTIGATIONS                             INVESTIGATIONS                                    INVESTIGATIONS                                                                                                          AUTO IMMUNE DISEASE
                                      Swab      Radiology         Pathology      Swab      Radiology           Pathology           Swab      Radiology         Pathology
                                                                                                                                                                                                                                                        SMOKER
                                  WOUND DESCRIPTION                           WOUND DESCRIPTION                                WOUND DESCRIPTION                                                                                                        OBESE
                                     % Wound Healed                              % Wound Healed                                   % Wound Healed
                                                                                                                                                                                                                                                        ____________________________________________________
                                     % Pink – Epitheliaziation                   % Pink – Epitheliaziation                        % Pink – Epitheliaziation
                                                                                                                                                                                                                                                        ____________________________________________________
                                     % Red – Granulation                         % Red – Granulation                              % Red – Granulation
                                                                                                                                                                                                                                                        ____________________________________________________
                                     % Yellow – Slough                           % Yellow – Slough                                % Yellow – Slough
                                     % Black – Necrotic                          % Black – Necrotic                               % Black – Necrotic                                                                                                    ____________________________________________________




                                                                                                                                                                                                                Binding Margin – Do Not Write Here
                                                                                                                                                                                                                                                        ____________________________________________________




                                                                                                                                                                           Binding Margin – Do Not Write Here
                                     % Green – Infected                          % Green – Infected                               % Green – Infected
                                     % Red – Hypergranulation                    % Red – Hypergranulation                         % Red – Hypergranulation                                                                                              ____________________________________________________
                                  Length _______      Unchanged               Length _______      Unchanged                    Length _______      Unchanged                                                                                            ____________________________________________________
                                  Width ________      Unchanged               Width ________      Unchanged                    Width ________      Unchanged                                                                                            ____________________________________________________
                                  Depth ________      Unchanged               Depth ________      Unchanged                    Depth ________      Unchanged
                                                                                                                                                                                                                                                                                       MEDICATIONS
                                  SURROUNDING SKIN                            SURROUNDING SKIN                                  SURROUNDING SKIN                                                                                                        ____________________________________________________
                                    Healthy     Blistered                       Healthy     Blistered                             Healthy     Blistered
                                                                                                                                                                                                                                                        ____________________________________________________
                                    Dry/Scaly   Macerated                       Dry/Scaly   Macerated                             Dry/Scaly   Macerated
                                                                                                                                                                                                                                                        ____________________________________________________
                                    Eczema      Inflammation                    Eczema      Inflammation                          Eczema      Inflammation
                                                                                                                                                                                                                                                        ____________________________________________________
                                    Mottled     Cellulitis                      Mottled     Cellulitis                            Mottled     Cellulitis
                                    Oedema      Heat                            Oedema      Heat                                  Oedema      Heat                                                                                                      ____________________________________________________
                                    Discoloured Hyperkeratosis                  Discoloured Hyperkeratosis                        Discoloured Hyperkeratosis
                                    Induration  Contact Dermatitis              Induration  Contact Dermatitis                    Induration  Contact Dermatitis                                                                                                                         ALLERGIES
                                  EXUDATE         TYPE        ODOUR           EXUDATE         TYPE        ODOUR                EXUDATE         TYPE        ODOUR                                                                                        ____________________________________________________
                                     Nil             Serous      Nil             Nil             Serous      Nil                  Nil             Serous      Nil                                                                                       ____________________________________________________                                                            PULSES + -
                                     Low             Purulent    Offensive       Low             Purulent    Offensive            Low             Purulent    Offensive
WOUND ASSESMENT AND MANAGEMENT




                                                                                                                                                                                                                                                                                                                                                                                                                     WOUND ASSESMENT AND MANAGEMENT
                                     Moderate        Haemoserous                 Moderate        Haemoserous                      Moderate        Haemoserous                                                                                                                  PRIMARY INVESTIGATIONS                                            DIAGNOSIS
                                     Heavy                                       Heavy                                            Heavy                                                                                                                 ANKLE / BRACHIAL INDEX _____________________________                                     VISTRAK MEASUREMENT                     Yes         No        N/A
                                     Other____________________________           Other____________________________                Other____________________________                                                                                                                                                                              DIGITAL IMAGING CONSENT                 Yes         No
                                  Drain number _____________     Removed      Drain number _____________     Removed           Drain number _____________     Removed                                                                                                                   PATHOLOGY
                                  Drainage     _____________ mls              Drainage     _____________ mls                   Drainage     _____________ mls                                                                                           LIVER FUNCTION TEST                          Yes         No         N/A                  X-RAY                                   Yes         No        N/A
                                  CLEANSING REGIME                            CLEANSING REGIME                                 CLEANSING REGIME                                                                                                         RENAL FUNCTION                               Yes         No         N/A                  ULTRASOUND                              Yes         No        N/A
                                    Irrigation    Sitz bath   Shower            Irrigation    Sitz bath   Shower                 Irrigation    Sitz bath   Shower                                                                                       BLOOD SUGAR LEVEL                            Yes         No         N/A                  B.M.I.                                  Yes         No        N/A
                                  Debridement:                                Debridement:                                     Debridement:                                                                                                             TISSUE BIOPSY                                Yes         No         N/A                  VASCULAR LABORATORY                     Yes         No        N/A
                                    Chemical      Surgical    Mechanical        Chemical      Surgical    Mechanical             Chemical      Surgical    Mechanical                                                                                   RADIOLOGY                                    Yes         No         N/A                  HAEMODYNAMIC STUDIES                    Yes         No        N/A
                                  PAIN SCORE         0 ↔ 5 ↔ 10               PAIN SCORE         0 ↔ 5 ↔ 10                    PAIN SCORE         0 ↔ 5 ↔ 10                                                                                            ANGIOGRAM                                    Yes         No         N/A
                                     Intermittent  Continuous   At dressing      Intermittent  Continuous   At dressing           Intermittent  Continuous   At dressing
                                      NURSING AIM                                NURSING AIM                                       NURSING AIM                                                                                                          Nursing Staff & Contact                                    Referral Made                                             Referral Attended
                                   __________________________________         __________________________________                __________________________________                                                                                        Service If Required                                      (Date & Sign)                                               (Date & Sign)
                                   __________________________________         __________________________________                __________________________________
                                   __________________________________         __________________________________                __________________________________                                                                                           Wound CNC                         ____/____/____         ________________________               ____/____/____        ________________________
                                                                                                                                                                                                                                                             Occupational Therapy              ____/____/____         ________________________               ____/____/____        ________________________
                                      DRESSING PRODUCTS                          DRESSING PRODUCTS                                 DRESSING PRODUCTS
                                                                                                                                                                                                                                                             Dietitian                         ____/____/____         ________________________               ____/____/____        ________________________
                                   __________________________________         __________________________________                __________________________________
                                   __________________________________         __________________________________                __________________________________                                                                                           Physiotherapy                     ____/____/____         ________________________               ____/____/____        ________________________
                                   __________________________________         __________________________________                __________________________________                                                                                           Podiatrist                        ____/____/____         ________________________               ____/____/____        ________________________
                                   __________________________________         __________________________________                __________________________________                                                                                           Continence CN                     ____/____/____         ________________________               ____/____/____        ________________________
                                      COMPRESSION _________________              COMPRESSION _________________                     COMPRESSION _________________                                                                                             Stomal Therapist                  ____/____/____         ________________________               ____/____/____        ________________________
                                                                                                                                                                                                                   TD504




                                   Dressing next due _________________        Dressing next due _________________               Dressing next due _________________                                                                                          Acute Pain Service                ____/____/____         ________________________               ____/____/____        ________________________
                                                                                                                                                                                                                                                             Diabetic Educator                 ____/____/____         ________________________               ____/____/____        ________________________
                                   WARD : …………………...……………                     WARD : …………………...……………                            WARD : …………………...……………                                                                                                       General Practitioner              ____/____/____         ________________________               ____/____/____        ________________________
                                                                                                                                                                                                                                                             Emergency Department              ____/____/____         ________________________               ____/____/____        ________________________
                                   NAME: …………………………..………                      NAME: …………………………..………                             NAME: …………………………..………                                                                                                        Hyperbaric Medicine Unit          ____/____/____         ________________________               ____/____/____        ________________________
                                   SIGN: ……………………………………                       SIGN: ……………………………………                              SIGN: ……………………………………                                                                                                           The Townsville Hospital wish to acknowledge the Gold Coast Health Service District for contributing to information contained in this document
                                 03/07                      Disclaimer: This tool is intended as a guide only and does not replace clinical judgement.                                                                                               03/07                            Disclaimer: This tool is intended as a guide only and does not replace clinical judgement.
                                                                                                                                                                                                                                                                                                                                  (Affix patient label here)
                                                                                                                         (Affix patient label here)                                                                                                                                                  URN:

                                                                                                  URN:                                                                                                                                                                                               Family Name:

                                                                                                  Family Name:                                                                                                                                                                                       Given Names:
                                                                                                                                                                                                                                                WOUND ASSESSMENT
                                           WOUND ASSESSMENT                                       Given Names:
                                                                                                                                                                                                                                                 AND MANAGEMENT                                      Date of Birth:                           Sex:        M       F

                                            AND MANAGEMENT                                        Date of Birth:                       Sex:       M       F                                                                                The Townsville Hospital
                                    The Townsville Hospital                                                                                                                                                                                     ASSESSMENT REQUIRED ONCE PER DAY ONLY, OR AT NEXT DRESSING ACCORDING TO FREQUENCY REGIME
                                                   NURSING STAFF: COMPLETE BELOW IN ENTIRETY AFTER INITIAL ASSESSMENT OF WOUND
                                                                                                                                                                                                                                          DRESSING DATE & TIME                       DRESSING DATE & TIME                              DRESSING DATE & TIME
                                                                                                                                                                                                                                          WOUND SITE                                 WOUND SITE                                        WOUND SITE
                                                                                                                                                                                                                                          FREQUENCY REGIMEN                          FREQUENCY REGIMEN                                 FREQUENCY REGIMEN
                                    ADMITTING CONSULTANT:                                          ADMITTING WARD:
                                    DATE ASSESSED:                                                 ALLERGIES:                                                                                                                            ANTIBIOTICS                                 ANTIBIOTICS                                      ANTIBIOTICS
                                    OPERATION PERFORMED:                                           AND/OR WOUND DIAGNOSIS:                                                                                                                 Yes →        Oral           IV              Yes →         Oral             IV                Yes →            Oral         IV
                                                                                                                                                                                                                                           No           Ceased                         No            Ceased                             No               Ceased
                                    CONTRIBUTING FACTORS:
                                    IF PRESSURE ULCER: Stage _________        PRIME Initiated    Pressure Ulcer Prevention and Management Resource                                                                                        INVESTIGATIONS                             INVESTIGATIONS                                    INVESTIGATIONS
                                    Guidelines’ Reviewed                                                                                                                                                                                     Swab      Radiology       Pathology        Swab      Radiology           Pathology           Swab      Radiology         Pathology
                                    WOUND SIZE:         Length: __________________   Width: ____________________      Depth:           Wound Intact                                                                                      WOUND DESCRIPTION                           WOUND DESCRIPTION                                WOUND DESCRIPTION
                                    WOUND DESCRIPTION                        SURROUNDING SKIN                                                                                                                                               _____ % Wound Healed                        _____ % Wound Healed                             _____ % Wound Healed
                                      _____ % Wound Healed                     Healthy                                                                                                                                                      _____% Pink – Epitheliaziation              _____% Pink – Epitheliaziation                   _____% Pink – Epitheliaziation
                                      _____ % Pink – Epitheliaziation          Dry/Scaly
                                                                                                                                                                                                                                            _____ % Red – Granulation                   _____ % Red – Granulation                        _____ % Red – Granulation
                                      _____ % Red – Granulation                Eczema
                                      _____ % Yellow – Slough                  Mottled                                                                                                                                                      _____ % Yellow – Slough                     _____ % Yellow – Slough                          _____ % Yellow – Slough
                                      _____ % Black – Necrotic                 Oedema                                                                                                                                                       _____ % Black – Necrotic                    _____ % Black – Necrotic                         _____ % Black – Necrotic




                                                                                                                                                                                                   Binding Margin – Do Not Write Here
                                      _____ % Green – Infected                 Discoloured                                                                                                                                                  _____ % Green – Infected                    _____ % Green – Infected                         _____ % Green – Infected




                                                                                                                                                              Binding Margin – Do Not Write Here
                                      _____ % Red – Hypergranulation           Induration                                                                                                                                                   _____ % Red – Hypergranulation              _____ % Red – Hypergranulation                   _____ % Red – Hypergranulation
                                      Sinus               Fistula              Hyperkeratosis
                                      Bulla/Blister       Haematoma            Blistered                                                                                                                                                 Length _______     Unchanged                Length _______     Unchanged                     Length _______     Unchanged
                                      Burn                Ulcer                Macerated                                                                                                                                                 Width ________     Unchanged                Width ________     Unchanged                     Width ________     Unchanged
                                      Surgical Incision   Cavity               Heat                                                                                                                                                      Depth ________     Unchanged                Depth ________     Unchanged                     Depth ________     Unchanged
                                      Inflammation        Cellulitis           Contact Dermatitis
                                                                                                                                                                                                                                         SURROUNDING SKIN                            SURROUNDING SKIN                                  SURROUNDING SKIN
                                    Due date for staples / sutures to be removed____/____/____                                                                                                                                             Healthy     Blistered                       Healthy     Blistered                             Healthy     Blistered
                                                                                                                                                                                                                                           Dry/Scaly   Macerated                       Dry/Scaly   Macerated                             Dry/Scaly   Macerated
                                    EXUDATE              TYPE              ODOUR                                                                                                                                                           Eczema      Inflammation                    Eczema      Inflammation                          Eczema      Inflammation
                                      Nil                  Nil               Drains in situ
                                      Low                  Serous            Swab Taken                                                                                                                                                    Mottled     Cellulitis                      Mottled     Cellulitis                            Mottled     Cellulitis
                                      Moderate             Haemoserous                                                                                                                                                                     Oedema      Heat                            Oedema      Heat                                  Oedema      Heat
                                      Heavy                Purulent          Offensive                                                                                                                                                     Discoloured Hyperkeratosis                  Discoloured Hyperkeratosis                        Discoloured Hyperkeratosis
                                                           Other _________                                                                                                                                                                 Induration  Contact Dermatitis              Induration  Contact Dermatitis                    Induration  Contact Dermatitis
                                                                                                                           Wound drawing / sketch
                                                                                                                                                                                                                                         EXUDATE         TYPE        ODOUR           EXUDATE         TYPE        ODOUR                EXUDATE         TYPE        ODOUR
                                    Wound Management Regime
                                                                                                                                                                                                                                            Nil             Serous      Nil             Nil             Serous      Nil                  Nil             Serous      Nil
                                    _______________________________________________________________________________________
                                                                                                                                                                                                                                            Low             Purulent    Offensive       Low             Purulent    Offensive            Low             Purulent    Offensive




                                                                                                                                                                                                                                                                                                                                                                                  WOUND MANAGEMENT AND ASESSMENT
WOUND ASSESMENT AND MANAGEMENT




                                    _______________________________________________________________________________________                                                                                                                 Moderate        Haemoserous                 Moderate        Haemoserous                      Moderate        Haemoserous
                                                                                                                                                                                                                                            Heavy                                       Heavy                                            Heavy
                                    _______________________________________________________________________________________
                                                                                                                                                                                                                                            Other____________________________           Other____________________________                Other____________________________
                                    _______________________________________________________________________________________                                                                                                              Drain number _____________     Removed      Drain number _____________     Removed           Drain number _____________     Removed
                                                                                                                                                                                                                                         Drainage     _____________ mls              Drainage     _____________ mls                   Drainage     _____________ mls
                                    _______________________________________________________________________________________
                                                                                                                                                                                                                                         CLEANSING REGIME                            CLEANSING REGIME                                 CLEANSING REGIME
                                    _______________________________________________________________________________________                                                                                                                Irrigation    Sitz bath   Shower            Irrigation    Sitz bath   Shower                 Irrigation    Sitz bath   Shower
                                                                                                                                                                                                                                         Debridement:                                Debridement:                                     Debridement:
                                    _______________________________________________________________________________________                                                                                                                Chemical      Surgical    Mechanical        Chemical      Surgical    Mechanical             Chemical      Surgical    Mechanical
                                    _______________________________________________________________________________________                                                                                                              PAIN SCORE         0 ↔ 5 ↔ 10               PAIN SCORE         0 ↔ 5 ↔ 10                    PAIN SCORE         0 ↔ 5 ↔ 10
                                                                                                                                                                                                                                            Intermittent  Continuous   At dressing      Intermittent  Continuous   At dressing           Intermittent  Continuous   At dressing
                                    _______________________________________________________________________________________                                                                                                                  NURSING AIM                                NURSING AIM                                       NURSING AIM
                                                                                                                                                                                                                                          __________________________________         __________________________________                __________________________________
                                    _______________________________________________________________________________________                                                                                                               __________________________________         __________________________________                __________________________________
                                                                                                                                                                                                                                          __________________________________         __________________________________                __________________________________
                                    _______________________________________________________________________________________
                                                                                                                                                                                                                                             DRESSING PRODUCTS                          DRESSING PRODUCTS                                 DRESSING PRODUCTS
                                    _______________________________________________________________________________________                                                                                                               __________________________________         __________________________________                __________________________________
                                                                                                                                                                                                                                          __________________________________         __________________________________                __________________________________
                                    _______________________________________________________________________________________                                                                                                               __________________________________         __________________________________                __________________________________
                                                                                                                                                                                                                                          __________________________________         __________________________________                __________________________________
                                    _______________________________________________________________________________________
                                                                                                                                                                                                                                             COMPRESSION _________________              COMPRESSION _________________                     COMPRESSION _________________
                                    _______________________________________________________________________________________                                                                                                               Dressing next due _________________        Dressing next due _________________               Dressing next due _________________

                                    _______________________________________________________________________________________                                                                                                               WARD : …………………...……………                     WARD : …………………...……………                            WARD : …………………...……………
                                                                                                                                                                                                                                          NAME: …………………………..………                      NAME: …………………………..………                             NAME: …………………………..………
                                         Upon discharge copy of Wound Assessment & Management Tool sent to Referred Agency
                                                                                                                                                                                                                                          SIGN: ……………………………………                       SIGN: ……………………………………                              SIGN: ……………………………………
                                 03/07                       Disclaimer: This tool is intended as a guide only and does not replace clinical judgement.                                                                                 03/07                      Disclaimer: This tool is intended as a guide only and does not replace clinical judgement.

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:3949
posted:4/27/2010
language:English
pages:2
Description: Wound Assessment and Management Tool