Documentation Guideline: Wound Assessment &Treatment Flow Sheet
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Arterial Leg Ulcer Clinical Pathway
Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Arterial Leg Ulcer Clinical Pathway 0-7 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) Refer patient to ‘Care Connects’ if no responsible practitioner currently involved with patient identified/informed Determine if MRP/NP is part of Family Health Team (FHT) or Community Health Centre (CHC) and consider additional supports available Medical/surgical history and co-morbidity management Risk factors include: Chronic renal disease considered within care plan Smoking Congestive heart failure Diabetes mellitus Impaired liver function Hyperlipidemia Use of systemic steroids, Hypertension immunosuppressive and chemotherapy Coronary artery disease >70 years of age History of cerebral vascular accident Age 50-69 years with history of diabetes (CVA) or smoking Low hemoglobin < 50 years with diabetes and one other Obesity atherosclerotic factor Poor nutrition History of vascular surgery or deep vein Decreased thyroid function thrombosis Psoriasis Bleeding disorders Autoimmune diseases Family history of arterial disease Medication reconciliation and their impact on wound healing Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, reviewed inhaled substances and nicotine replacement therapy) Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs Other -
Recognizing When a Child's Injury Or Illness Is Caused by Abuse
U.S. Department of Justice Office of Justice Programs Office of Juvenile Justice and Delinquency Prevention Recognizing When a Child’s Injury or Illness Is Caused by Abuse PORTABLE GUIDE TO INVESTIGATING CHILD ABUSE U.S. Department of Justice Office of Justice Programs 810 Seventh Street NW. Washington, DC 20531 Eric H. Holder, Jr. Attorney General Karol V. Mason Assistant Attorney General Robert L. Listenbee Administrator Office of Juvenile Justice and Delinquency Prevention Office of Justice Programs Innovation • Partnerships • Safer Neighborhoods www.ojp.usdoj.gov Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov The Office of Juvenile Justice and Delinquency Prevention is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance; the Bureau of Justice Statistics; the National Institute of Justice; the Office for Victims of Crime; and the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking. Recognizing When a Child’s Injury or Illness Is Caused by Abuse PORTABLE GUIDE TO INVESTIGATING CHILD ABUSE NCJ 243908 JULY 2014 Contents Could This Be Child Abuse? ..............................................................................................1 Caretaker Assessment ......................................................................................................2 Injury Assessment ............................................................................................................4 Ruling Out a Natural Phenomenon or Medical Conditions -
Protocols for Injuries to the Eye Corneal Abrasion I
PROTOCOLS FOR INJURIES TO THE EYE CORNEAL ABRASION I. BACKGROUND A corneal abrasion is usually caused by a foreign body or other object striking the eye. This results in a disruption of the corneal epithelium. II. DIAGNOSTIC CRITERIA A. Pertinent History and Physical Findings Patients complain of pain and blurred vision. Photophobia may also be present. Symptoms may not occur for several hours following an injury. B. Appropriate Diagnostic Tests and Examinations Comprehensive examination by an ophthalmologist to rule out a foreign body under the lids, embedded in the cornea or sclera, or penetrating into the eye. The comprehensive examination should include a determination of visual acuity, a slit lamp examination and a dilated fundus examination when indicated. III. TREATMENT A. Outpatient Treatment Topical antibiotics, cycloplegics, and pressure patch at the discretion of the physician. Analgesics may be indicated for severe pain. B. Duration of Treatment May require daily visits until cornea sufficiently healed, usually within twenty-four to seventy-two hours but may be longer with more extensive injuries. In uncomplicated cases, return to work anticipated within one to two days. The duration of disability may be longer if significant iritis is present. IV. ANTICIPATED OUTCOME Full recovery. CORNEAL FOREIGN BODY I. BACKGROUND A corneal foreign body most often occurs when striking metal on metal or striking stone. Auto body workers and machinists are the greatest risk for a corneal foreign body. Hot metal may perforate the cornea and enter the eye. Foreign bodies may be contaminated and pose a risk for corneal ulcers. II. DIAGNOSTIC CRITERIA A. Pertinent History and Physical Findings The onset of pain occurs either immediately after the injury or within the first twenty-four hours. -
Skin Injuries – Can We Determine Timing and Mechanism?
Skin injuries – can we determine timing and mechanism? Jo Tully VFPMS Seminar 2016 What skin injuries do we need to consider? • Bruising • Commonest accidental and inflicted skin injury • Basic principles that can be applied when formulating opinion • Abrasions • Lacerations }we need to be able to tell the difference • Incisions • Stabs/chops • Bite marks – animal v human / inflicted v ‘accidental’ v self-inflicted Our role…. We are often/usually/always asked…………….. • “What type of injury is it?” • “When did this injury occur?” • “How did this injury occur?” • “Was this injury inflicted or accidental?” • IS THIS CHILD ABUSE? • To be able to answer these questions (if we can) we need knowledge of • Anatomy/physiology/healing - injury interpretation • Forces • Mechanisms in relation to development, plausibility • Current evidence Bruising – can we really tell which bruises are caused by abuse? Definitions – bruising • BLUNT FORCE TRAUMA • Bruise =bleeding beneath intact skin due to BFT • Contusion = bruise in deeper tissues • Haematoma - extravasated blood filling a cavity (or potential space). Usually associated with swelling • Petechiae =Pinpoint sized (0.1-2mm) hemorrhages into the skin due to acute rise in venous pressure • medical causes • direct forces • indirect forces Medical Direct Indirect causes mechanical mechanical forces forces Factors affecting development and appearance of a bruise • Properties of impacting object or surface • Force of impact • Duration of impact • Site - properties of body region impacted (blood supply, -
Medical Term for Scrape
Medical Term For Scrape protozoologicalIncomprehensible Mack Willmott federalized fraction fermentation some decimeter and tickle after hishyphenated rusticator Thornie revengingly overtasks and owlishly. perforce. Zedekiah Lecherous and andbeseeched grippier. his focussing lobes challengingly or contritely after Mayor knee and previews angelically, unmasking Ttw is for scrape may require stitches to medications and support a knee sprains heal closed wounds such as terms at harvard medical history does not. This medical terms for scraping can be. Ancient Chinese medical treatment leaves lasting impressions. Lifting the cloth, gauze, or bandage to check on the wound may cause additional bleeding, so it is important to continue to maintain firm pressure over the abrasion. Many people with their expertise in cross section is the risk for teaching hospital but all are a scrape for their location. Please stand by, while we are checking your browser. It helps prepare the tooth for this procedure and can also be used on the root of a tooth is needed. Abrasion this grant the medical term for scraped skin This happens when an injury scrapes off the particular layer of talking skin A person may say the he. How to scrape for scrapes and ice pack or treatment may be avoided in terms as a term for dentures that gives back to treat a lawyer. Antibiotics For Wound Infection PlushCare. Gua sha Scraping of low is able to relieve pain more ease. Awareness of your surroundings and paying close trip to in you need doing my help manual the likelihood of an accidental scrape, plane, or injury. Please consult your health care provider with any questions or concerns you may have regarding your condition. -
The Triangle of Wound Assessment a Simple and Holistic Framework for Wound Management
The Triangle of Wound Assessment A simple and holistic framework for wound management Wound bed WOUND Wound edge Periwound skin We asked healthcare professionals around the world about their priorities ? for wound care We found that most people Respondents said that treating wounds are not protecting the periwound specialists in a hospital1 skin is very important1 Approximately Up to 79% of wounds are 70% of being treated in wounds are the community2 surrounded by unhealthy skin3 2 ...none However, in a recent met all of the study of 14 wound criteria for assessment tools ... optimal wound assessment4 The Triangle of Wound Assessment is a holistic framework that allows practitioners üto assess and manage all areas of the wound, including the periwound skin. It is a simple and systematic approach that guides the user Wound bed from complete wound WOUND assessment to setting management goals, and Wound edge Periwound skin selecting the optimal treatment. 3 The Triangle of Wound Assessment offers a systematic approach to wound management Optimal wound management starts with a holistic wound assessment. This will help to more efficiently set management goals, which will increase the potential for better treatment outcomes. Assessment Management Goals Treatment 4 This is achieved through a holistic framework The Triangle of Wound Assessment provides a framework to assess all three areas of the wound while remembering the patient behind the wound within their social context. Patient Wound bed Social context WOUND Wound Wound edge Periwound skin 5 It’s not just about the wound but also the patient behind the wound Optimal management of the wound starts with assessing the patient behind the wound, and the social context in which the patient lives. -
Guideline: Wound Bed Preparation for Healable and Non Healable Wounds
British Columbia Provincial Nursing Skin and Wound Committee Guideline: Wound Bed Preparation for Healable and Non Healable Wounds Developed by the BC Provincial Nursing Skin and Wound Committee in collaboration with Wound Clinicians from: / TITLE Guideline: Wound Bed Preparation for Healable and Non-Healable Wounds in Adults & Children1 Practice Level Nurses in accordance with health authority and agency policy. Conservative sharp wound debridement (CSWD) is a restricted activity according to the Nurse’s (Registered) and Nurse Practitioner Regulation. 2 CRNBC states that registered nurses must successfully complete additional education and follow an established guideline when carrying out CSWD. Biological debridement therapy is a restricted activity according to the Nurse’s (Registered) and Nurse Practitioner Regulation. 3 CRNBC states that registered nurses must follow an established guideline when carrying out biological debridement. Clients 4 with wounds needing wound bed preparation require an interprofessional approach to provide comprehensive, evidence-based assessment and treatment. This clinical practice guideline focuses solely on the role of the nurse, as one member of the interprofessional team providing care to these clients. Background Factors affecting wound healability include the presence of adequate circulation in the area of the wound, wound related factors such as the size and duration of the wound, the ability to treat the cause of the wound and the presence of risk factors impacting wound healing. While many wounds heal, others are determined to be non-healing or slow-to-heal based on the presence or absence of these factors. Wound healability must be determined prior to debridement and moist wound healing. Although wound healing normally occurs in a predictable fashion, wound healing trajectories can be heterogeneous and non- uniform resulting is delayed wound healing for some clients. -
A Focus on the Triangle of Wound Assessment — Addressing the Gap Challenge and Identifying Suspected Biofilm in Clinical Practice
Clinical practice A focus on the Triangle of Wound Assessment — addressing the gap challenge and identifying suspected biofilm in clinical practice Authors: Wound assessment should be comprehensive, systematic and evidence- Caroline Dowsett, Terry Swanson and Tonny Karlsmark based (World Union of Wound Healing Societies [WUWHS], 2016a). The Triangle of Wound Assessment offers clinicians a framework to assess the patient and their wound, taking into consideration the wound bed, wound edge and periwound skin (Dowsett et al, 2015). The framework can be adapted to incorporate new developments and new challenges in wound care such as the ‘gap challenge’ and biofilm prevention and management. Using the framework can assist in determining the status of the wound bed and support clinical decision making to prevent problems associated with exudate pooling at the wound bed and the potential for biofilm formation. he Triangle of Wound Assessment This article will discuss how the Triangle of was established in 2014 and provides Wound Assessment identifies infection and T a systematic approach to wound biofilm, tackles the gap challenge, and how assessment and in setting management goals, this framework can be developed for new to guide optimal treatment choice (Dowsett et challenges in wound care. al, 2015), ensuring that the periwound skin is incorporated into the assessment. Periwound The importance of holistic assessment skin can be a significant problem in patients Wounds are a significant source of cost to with chronic wounds, with between 60–70% patients, as well as to the health economy. of wounds found to be surrounded by either Chronic wounds are often hard to heal problematic or unhealthy periwound skin resulting in a cycle of pain, anxiety and (Cartier et al, 2014). -
Clinician Assessment Tools for Patients with Diabetic Foot Disease: a Systematic Review
Journal of Clinical Medicine Review Clinician Assessment Tools for Patients with Diabetic Foot Disease: A Systematic Review Raúl Fernández-Torres 1 , María Ruiz-Muñoz 1,* , Alberto J. Pérez-Panero 1 , Jerónimo C. García-Romero 2 and Manuel Gónzalez-Sánchez 3 1 Department of Nursing and Podiatry, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación Campus de Teatinos, 29071 Málaga, Spain; [email protected] (R.F.-T.); [email protected] (A.J.P.-P.) 2 Medical School of Physical Education and Sports, University of Málaga, C/Jiménez Fraud 10. Edificio López de Peñalver, 29010 Málaga, Spain; [email protected] 3 Department of Physiotherapy, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos, 29071 Málaga, Spain; [email protected] * Correspondence: [email protected]; Tel.: +34-951953215 Received: 10 April 2020; Accepted: 12 May 2020; Published: 15 May 2020 Abstract: The amputation rate in patients with diabetes is 15 to 40 times higher than in patients without diabetes. To avoid major complications, the identification of high-risk in patients with diabetes through early assessment highlights as a crucial action. Clinician assessment tools are scales in which clinical examiners are specifically trained to make a correct judgment based on patient outcomes that helps to identify at-risk patients and monitor the intervention. The aim of this study is to carry out a systematic review of valid and reliable Clinician assessment tools for measuring diabetic foot disease-related variables and analysing their psychometric properties. The databases used were PubMed, Scopus, SciELO, CINAHL, Cochrane, PEDro, and EMBASE. The search terms used were foot, ankle, diabetes, diabetic foot, assessment, tools, instruments, score, scale, validity, and reliability. -
Assessment and Management of Pressure Injuries for the Interprofessional Team Third Edition Disclaimer
Clinical Best Practice Guidelines MAY 2016 Assessment and Management of Pressure Injuries for the Interprofessional Team Third Edition Disclaimer Th ese guidelines are not binding on nurses, other health care professionals, or the organizations that employ them. Th e use of these guidelines should be fl exible, and based on individual needs and local circumstances. Th ey neither constitute a liability nor discharge from liability. While every eff ort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury, or expense arising from any such errors or omissions in the contents of this work. Copyright With the exception of those portions of this document for which a specifi c prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety, without modifi cation, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from RNAO. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses’ Association of Ontario (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team, Th ird Edition. Toronto, ON: Registered Nurses’ Association of Ontario. Th is work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by RNAO is editorially independent from its funding source. -
(RNAO) – Risk Assessment & Prevention of Pressure Ulcers
Revised March 2005 Nursing Best Practice Guideline Shaping the future of Nursing Risk Assessment & Prevention of Pressure Ulcers Greetings from Doris Grinspun Executive Director Registered Nurses’ Association of Ontario It is with great excitement that the Registered Nurses’ Association of Ontario disseminates this revised nursing best practice guideline to you. Evidence-based practice supports the excellence in service that nurses are committed to deliver in our day-to-day practice. The RNAO is committed to ensuring that the evidence supporting guideline recommendations is the best available, and this guideline has been recently reviewed and revised to reflect the current state of knowledge. We offer our endless thanks to the many institutions and individuals that are making RNAO’s vision for Nursing Best Practice Guidelines (NBPG) a reality. The Government of Ontario recognized RNAO’s ability to lead this program and is providing multi-year funding. Tazim Virani – NBPG program director – with her fearless determination and skills, is moving the program forward faster and stronger than ever imagined. The nursing community, with its commitment and passion for excellence in nursing care, is providing the knowledge and countless hours essential to the creation, evaluation and revision of each guideline. Employers have responded enthusiastically by getting involved in nominating best practice champions, implementing and evaluating the NBPG and working towards an evidence-based practice culture. Now comes the true test in this phenomenal journey: will nurses utilize the guidelines in their day-to-day practice? Successful uptake of these NBPG requires a concerted effort of four groups: nurses themselves, other healthcare colleagues, nurse educators in academic and practice settings, and employers. -
Best Practice Recommendations for T
CLINICAL PRACTICE Best Practice Recommendations for Preparing the Wound Bed: Update 2006 BY R. Gary Sibbald, MD, FRCPC; Heather L. Orsted, RN, BN, ET, MSc; Patricia M. Coutts, RN; and David H. Keast, MSc, MD, FCFP Abstract This article updates the concept of Preparing the wound bed by intended for translation into practice. considering the whole patient (treatment of the cause and patient- This update of the Preparing the wound bed approach has the benefit centred concerns) before treating the wound. Local wound care of connecting the recommendations to the evidence as identified consists of tissue debridement, control of persistent inflammation through the Registered Nurses’ Association of Ontario’s (RNAO) or infection, and moisture balance before considering advanced Nursing Best Practice Guidelines. To date, the RNAO has published therapies for wounds that are not healing at the expected rate. The three guidelines related to the treatment of wounds (pressure, venous best practice recommendations are based on scientific evidence and diabetic), and the components related to local wound care are and expert opinion, and should include patient preference. They are included in this review. Introduction he concept of Preparing the wound bed was first FIGURE 1 described in 2000 by Sibbald et al. and Falanga.1,2 This Preparing the Wound Bed Paradigm T approach to wound management stresses that successful diagnosis and treatment of patients with chronic wounds Person with a Chronic Wound require holistic care and a team approach. The whole patient must be considered before looking at the wound itself. Figure 1 illustrates that wound bed preparation is the promotion of wound closure through Treat the Cause Local Patient-centred diagnosis and appropriate treatment of the cause, attention to • Address causes Wound Care Concerns patient-centred concerns, and correction of the systemic and local and co-factors • Adherence to plan of care factors that may be delaying healing.