Pressure Ulcer Prevention and Management - Sydney South West ...

Appendix 2Waterlow Pressure Ulcer Management FlowchartNOT AT RISK < 10AT RISK 10+HIGH RISK 15+VERY HIGH RISK 20+PRESSUREULCERNo managementunless change inconditionWaterlow assessmentto be completed everyweek or morefrequently if change inconditionDocument in thepatient/client healthcare record and on thecare planIdentify level of riskManage as perprevention strategiesChoose a pressuresupport system accordingto the level of risk(Appendix 4)Dietician referral to assessthe patient/clients nutritionalstatus & dietaryrequirementsWaterlow assessment to becompleted every week ormore frequently if change inconditionEnter into IIMS. Whenappropriate contact woundcare specialistDocument in thepatient/client health carerecord and on the woundmanagement chartChoose a pressuresupport system accordingto the level of risk(Appendix 4)Dietician referral to assessthe patient/clients nutritionalstatus & dietaryrequirements & hydrationPressure ulcer woundmanagement as pertreatment protocolsContact wound carespecialist for advice &assistance re pressureulcerReview ulcer at eachdressing change. Documentin health care record woundmanagement chartDocument in thepatient/client health carerecord and on the careplanAny patient/client with agrade 3-4 pressure ulcer isto remain at High Risk fortheir entire admissionService required Date contacted SignatureEntered into IIMS YES NOEquipment Hire required YES NOCompany contacted YES NOWound Care Specialist YES NODietician YES NOInterventional strategies implemented:PLEASE NOTE: Any patient that has suffered a Stage 3 or 4 pressure ulcer in the past is ‘At Risk’ of developinganother and is to be treated as HIGH RISK throughout their entire admission