Pressure Ulcer exam
classification [radio name="variable_1" value="pressure|vascular|terminal"] Risk factors [checklist name="variable_1" value="medications affecting wound healing (corticosteroids, sedatives)|exposure of skin to urinary of fecal incontinence|past history of pressure ulcer| impaired blood flow, PVD|Increase in friction or shear|Cognitive impairment|Patient refusal of some aspects of care or treatment|comorbid conditions (dysphagia, hemiplegia, obesity|nutritional compromise"] Staging[radio name="variable_1" value="Stage 1 -altered intact skin when compared to adjacent tissue|Stage 2 - partial thickness loss of dermis, shallow open ulcer|Stage 3 - full-thickness tissue loss, may include undermining or tunneling|Stage 4 - Full-thickness tissue loss with exposed bone, tendon or muscle| Unstageable - extent of tissue damage cannot be confirmed due to slough or eschar |Deep Tissue injury - purple or maroon discolored intact skin, damage of underlying tissue"] Exam [textarea name="variable_1" default="Location, Size (L x W x D), Ulcer bed (eschar, necrotic tissue, slough, granulation, moisture), exudate (seroosanguinous, purulent, odor, pain, color, periwound tissue (viable, macerated, inflamed, hperkeratotic, tunneling)"] Recommendation and Plan of Care: [checklist name=""variable_1" value=" Nutritional support - supplement with Zinc, Vitamin C,A,D, Hydration or protein supplement|Pressure management (reposition q 2, alternating pressure bed, prevalon heel protectors, PT)|debridement (autolytic, enzymatic, mechanical, surgical)|Cleaning with |Dressing and frequency (hydrocolloid, foam, alginate) |Culture and treat appropriately"]
There are 5 form elements.
Result - Copy and paste this output:
One response to “Pressure Ulcer exam”
More SOAPnotes by this Author: