On-Time Pressure Ulcer Healing Project Form 2: Wound Assessment: Ulcer Information (continued)Describes new tools to document pressure ulcer healing and treatments as part of the On-Time Quality Improvement Program. Report DateM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|DTreatments (check all that apply)No change since last report date; treatment remains appropriate Antimicrobials 1: acetic acid 2: Dakin's or hydrogel acid3: povidone iodine or Betadine 4: Other Barrier cream Cleansing & Irrigation: Commercial wound cleanser products Saline Soap and Water Whirlpool Dressing: Calcium alginates Collagen Foam dressing Gauze dressing - Dry Gauze dressing - Moist Hydrogel amorphous Hydrogel impregnated gauze Hydrogel sheet dressing Hydrocolloid dressing Petroleum impregnated gauze dressing Transparent film dressing Debridement: Autolytic Enzymatic Mechanical Sharp Surgical Open to air Other Adjunctive Therapies (check all that apply)No change since last report date; adjunctive therapy appropriate Cytokine growth factors Diathermy Electrical stimulation Hyperbaric oxygen Low-energy laser radiation Negative pressure wound therapy (NPWT) Normothermia Ultrasound: Low frequency (L) High frequency (H) Ultraviolet radiation Interventions ( check all that apply)No change since last report date: interventions remain appropriate Intervention to maintain / improve nutrition & hydration status Monitoring of skin integrity and tissue tolerance Minimize exposure to moisture, including but not limited to, fecal and urinary contamination, perspiration Minimize risk for sheer and friction Monitor protein intake, calorie intake, vitamin & mineral supplements Monitor for labs as ordered by physician or facility protocol, including but not limited to, Hb, albumin, serum transferrin Support Surfaces for Bed: Air-fluidized surface Dynamic/alternating pressure surface Low-air-loss surface Replacement mattresses Static support Support Surfaces for WC: Air cushions Fluid-filled or gel cushions Foam cushions Combination cushions Other Support Surfaces: Heel boots Teaching: resident teaching to redistribute pressure; reposition & offloading; risks & benefits Turning and proper positioning: turning schedule Vitamins and Supplements: Arginaid Multivitamins Nutritional supplement Vitamin C Zinc Consultation (check all that apply)Dietitian ET nurse Plastics clinic/surgical clinic Rehab/in-house physical therapy Surgeon Wound clinic Wound nurse consultant Other Followup Ulcer StatusHealed Improving No change Worsening Current Visualized Ulcer StageThe facility acknowledges that NPUAC and WOCN recommend not to downstage pressure ulcers. However, to comply with Medicare and Medicaid documentation requirements, pressure ulcer will be staged as visualized at the time of each reporting period. If resident is discharged, enter stage of ulcer at time of discharge. Stage I Stage II Stage III Stage IV Unstageable Resident DispositionResident discharged since last report date Resident expired since last report date Comments Return to Contents Current as of July 2009 Internet Citation: On-Time Pressure Ulcer Healing Project: Form 2: Wound Assessment: Ulcer Information (continued). July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcerhealing/waform2a.html
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