RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

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Assessment & Management of Stage I to IV Pressure UlcersSample ii) Wound/Wound Care Discharge Transfer ToolDeveloped by N. Bauer and R. Kohr. Published with permission.Page 1 of 2PATIENT INFORMATIONDischarge/Transfer Date: Discharge Unit: Unit Ext #:Nurse Signature & Professional Designation:WOUND/SKIN INFORMATION❏ Skin Intact ❏ Altered Skin Integrity ❏ Skin Intact & Risk for Skin BreakdownWound Type(s): ❏ Pressure (Please Stage) ❏ I ❏ II ❏ III ❏ IV ❏ X ❏ Healed❏ Abrasion/Skin Tear ❏ Laceration ❏ Surgical ❏ Burn ❏ Venous Ulcer❏ Arterial Ulcer ❏ Diabetic Ulcer ❏ Other❏ Wound Size & Location – See Page 2 For Diagrams & MeasurementsWound Condition (Check all that apply): ❏ Improving ❏ Stable Non-Healing❏ Stable At-Risk ❏ Palliative ❏ Deteriorating ❏ InfectedPressure Reduction Equipment Needed (Check all that apply)Current Treatment Frequency (Check all that apply)❏ Low Air Loss Mattress❏ PRN❏ Pressure Reduction Foam Mattress❏ Every Other Day❏ Pressure Reduction Seating ❏ Daily ❏ BID ❏ TID ❏ QID❏ Pressure Relief – Heels❏ Other❏ OtherPeri-Wound Skin Treatment: ❏ None Needed ❏ Vaseline ❏ Zinc Oxide❏ Barrier Cream/Ointment (e.g., Cavalon) ❏ OtherCleaning Agent Currently Used (Check all that apply)Gels/Cream/Ointments Currently Used(Check all that apply)❏ Normal Saline ❏ Wound Cleanser ❏ Hydrogel (e.g., Intrasite Gel ® ) ❏ Calmoseptine ®❏ Sterile Water ❏ Bactroban ❏ Fucidine ❏ Flamazine❏ Other❏ OtherDressing Products Currently Used (Check all that apply)Commonly Used DressingsImpregnated Dressings❏ Gauze Dressings ❏ Cadexomer Iodine (Iodosorb ® )❏ 2x2s ❏ 4x4s ❏ ABDs ❏ Kling ❏ Nugauze ® ❏ Charcoal Dressing (Actisorb Plus ® ) ❏ Mesalt ®❏ Film (e.g., Tegaderm ® ) ❏ Silver Dressing (e.g., Aquacel Ag ® )❏ Liquid film (e.g., 3M No-Sting ® )❏ Other❏ Hydrocolloid (e.g., Duoderm ® /Tegasorb ® )❏ Calcium Alginate (e.g., Kaltostat ® )Super Absorbent Dressing MaterialsWound Contact Materials ❏ Hydrofibre (e.g., Aquacel ® )❏ Mepitel ® ❏ Sponge/Foam (e.g., Allevyn /Mepilex ® )❏ Mepilex Border ®❏ Wound Drainage Collector (e.g., Ostomy System)❏ Tegapore ® ❏ Combination Dressing (e.g., Mepilex Border ® )Compression Dressing (Identify) ❏ Negative Pressure Therapy (e.g., VAC ® )Comments on past problems and products used:❏ Other106
Nursing Best Practice GuidelineSample ii) Wound/Wound Care Discharge Transfer Tool Page 2 of 2PLANTAR VIEWDORSAL VIEWRightLeft Left RightRightLateral ViewLeftLateral ViewRightMedial ViewLeftMedial View107
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