On-Time Pressure Ulcer Healing Project: Form 2: Wound Assessment: Ulcer Information

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Form 2: Wound Assessment: Ulcer Information (continued)

Report Date	M\|M\|D\|D		M\|M\|D\|D		M\|M\|D\|D		M\|M\|D\|D		M\|M\|D\|D		M\|M\|D\|D
Treatments (check all that apply)
No change since last report date; treatment remains appropriate
Antimicrobials 1: acetic acid 2: Dakin's or hydrogel acid 3: 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 Status
Healed
Improving
No change
Worsening
Current Visualized Ulcer Stage
The 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 Disposition
Resident discharged since last report date
Resident expired since last report date
Comments

Current as of July 2009

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Internet Citation:

On-Time Pressure Ulcer Healing Project: Form 2: Wound Assessment: Ulcer Information. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/pressureulcerhealing/waform2.htm