RODWELL HOUSE WOUND ASSESSMENT
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1 RODWELL HOUSE WOUND ASSESSMENT Resdent Name: Sute No: Wound Type: Locaton: Grade: Photograph Date Taken:
2 Tssue Vablty: Wound Assessment Patent Label or Wrte Informaton Referrals Made (Please tck) RIO No Tssue Vablty NHS No Vascular Patent Name Podatry Date of Brth D D M M Y Y Age Plastcs Detcan Ward / Unt Other: Prmary Wound Type (Please tck) Pressure Ulcer Dabetc Foot Ulcer: Category: Complete Datx Form Refer to Dabetc Foot Team and Insert Date Above Leg Ulcer: Surgcal Wound Factors Whch May Delay Healng (Please tck) Skn Tear Dabetes Anema Fungatng Tumour COPD Ischema Burn / Scald Heart Falure Rheumatod Arthrts Mosture Assocated Skn Dermatts (MASD) Chronc Kdney Dsease Cancer Traumatc Wound Smokng Radotherapy / Chemotherapy Other: Nutrton or obesty problems Sterods / NSAIDS Wound Locaton (Please crcle) Rght Foot Left Foot Wound Duraton (please tck) <1-2 weeks 2-4 weeks 1-3 months 4-6 months 7-12 months 1-2 years >2 years Tssue Vablty Wound Assessment & Management Plan v2 1
3 Patent Name Tssue Vablty: Wound Detals = May Indcate Infecton Sze (cm/mm) Length Wdth Is wound reducng In sze? If not Investgate cause. Depth Wound Bed Enter the percentage of each tssue type vsble Necrotc (Black) % % % % % % % Sloughy (Yellow) % % % % % % % Granulatng (Red) % % % % % % % Epthlalsng (pnk) % % % % % % % Low Exudate Levels An ncrease n exudate can be an ndcaton of nfecton Management Tps: Do not apply mosture to schemc areas. Consder vascular referral Consder debrdement Smple atraumatc dressng Softpore Dressng Choce: Softpore Moderate Absorbent foam dressng Hgh Super absorbent Serous (Straw) Haemoserous (Red/Straw) Purulent (Green, Brown, Yellow) Exudate Type Could ndcate the frst sgn of nfecton Swab for culture and antmcrobal dressng Macerated (Whte) Oedematous Erythema (Red) Excorated (Red) Dry Surroundng Skn condton of surroundng skn & Mantenance s as mportant as the wound be Manage excess mosture & apply barrer cream to surroundng skn - Elevate lmb f able - Reverse cause of oedema Determne cause Manage Mosture & apply barrer cream Promote rehydraton, apply emollent Rate 0 10 Pan Assessment: (No Pan = 0) (10 = Worst Pan) Refer to doctor (f pan not controlled) Intals Tssue Vablty Wound Assessment & Management Plan v1.3 2
4 Patent Name Tssue Vablty: Treatment Plan & Evaluaton of Care Startng Plan Prmary Dressng Secondary dressng wrst to shoulder Frequency of Dressng change Management Am granulaton Bactera odour Hydrate Absorb Protect Keep Dry Evaluaton & Ratonale for dressng type (mprovng / statc /deterorated) Consder pan relef Nurse Name Date Sgnature Revsed Plan 1 Prmary Dressng Secondary dressng wrst to shoulder Frequency of Dressng change Management Am granulaton Bactera odour Hydrate Absorb Protect Keep Dry Evaluaton & Ratonale for chosen dressng type (mprovng / statc /deterorated) Consder pan relef Nurse Name Date Sgnature Tssue Vablty Wound Assessment & Management Plan v1.3 3
5 Patent Name Tssue Vablty: Treatment Plan & Evaluaton of Care Revsed Plan 2 Prmary Dressng Secondary dressng wrst to shoulder Frequency of Dressng change Management Am granulaton Bactera odour Hydrate Absorb Protect Keep Dry Evaluaton & Ratonale for chosen dressng type (mprovng / statc /deterorated) Consder pan relef Nurse Name Date Sgnature Revsed Plan 3 Prmary Dressng Secondary dressng wrst to shoulder Frequency of Dressng change Management Am granulaton Bactera odour Hydrate Absorb Protect Keep Dry Evaluaton & Ratonale for chosen dressng type (mprovng / statc /deterorated) Consder pan relef Nurse Name Date Sgnature Tssue Vablty Wound Assessment & Management Plan v1.3 4
6 Patent Name Tssue Vablty: Evaluaton Notes Date & Tme Evaluaton Sgnature & Role Tssue Vablty Wound Assessment & Management Plan v1.3 5
7 Patent Name Tssue Vablty: Gude to Common Dressngs on ONPOS Dressng Indcatons Contrandcatons Softpore Absorbent Pads/Low Adherent Dressng Dry or sutured wounds Superfcal cuts or abrasons Mnmal exudate Hghly exudng wounds Necrotc or sloughy wounds Adaptc touch/n-a Ultra Non-Adherent Dressng (requres secondary dressng) Granulatng wounds Requres secondary dressng Allergy to slcone Duoderm/Granuflex Hydrocollod Aquacel Extra Hydrofbre (requres secondary dressng) Batan adhesve/non adhesve Absorbent slcone foam Iodoflex Antmcrobal Actcoat, Actcoat flex, Aquacel Ag Antmcrobal Slver Actvon/Algvon Honey Partal and full thckness wounds Supports autolytc debrdement Mantans a most envronment Protecton to ntact skn around negatve pressure wound therapy Moderate to heavly exudng wounds Rbbon to pack cavtes Supports autolytc debrdement To mantan most envronment Moderate to heavly exudng wounds Infected wounds Sloughy wounds To reduce boburden Localsed nfecton Spreadng nfecton Systemc nfecton Malodourous wounds Sloughy wounds Acts as an ant-nflammatory Can stmulate healng Hghly exudng wounds Presence of nfecton Dabetc foot ulcers *Contans gelatne derved from Pork. Consder patents wth relgous or ethcal objectons* Dry wounds wth mnmal exudate Dry wounds wth mnmal exudate Do not cover wth flm dressng as ths restrcts water vapour loss Chldren Pregnant or lactatng women Renal Imparment Thyrod dsorders Patents prescrbed Lthum Maxmum sngle applcaton 50g, 150g weekly. *Successve treatment should not exceed 2 weeks* Patents wth senstvty to slver Patents undergong and MRI scan Pror to radotherapy treatment (can be reappled after treatment) Where boburden s not an ssue Patents wth an allergy to bee stngs or extreme senstvty to honey References Natonal best practce and evdence based gudelnes for wound management. Avalable from: woundgudelnes.pdf Wound assessment tools and nurses needs: an evaluaton study, Shela Greatrex-Whte & Helen Moxey. Internatonal Wound Journal ISSN Author: Paulne Robnson, Tssue Vablty Nurse Specalst. Desgn, Graphcs and Edtng: Smon Pawln Tssue Vablty Wound Assessment & Management Plan v1.3 6
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