Wwwoundcare.ca



-92710-245745Waterloo Wellington Integrated Wound Care ProgramEvidence-Based Wound Care Pressure Injury Clinical Pathway0-7 Days Expected OutcomesNotesPatient admitted to service/facilityMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patientDetermine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports availableMedical/surgical history and co-morbidity management considered within care planAny diagnosis that affects mobility, cognition, sensation and communication may be the cause of risk factors for Pressure InjurysSensory PerceptionNeuropathyGlycosylation (sugar attaches to cells)of tissues Sensory impairment/altered level of consciousnessDecreased cognitive abilityMoistureMoisture on skin (e.g. bladder and bowel incontinence, wound or fistula exudate, diaphoresis)EdemaAltered skin integrity/previous ulcerationsActivity (degree of physical activity)Immobility (bedrest, head of bed elevation >300, chair sitting for prolonged times, hip fractures, supine or prone positioning)Decreased level of activityChronic or end of life painComorbidity that causes physical limitationsMobility (ability to change and control body position)ObesityProlonged anesthesia/operating room timePrematurityAdvanced ageEnd of lifeCritically injured statusUncontrolled body movementsCongenital abnormalitiesNutritionNutritional deficitsAlcohol/drug abuseFriction, Pressure and ShearUnsafe transfersMedical devices (e.g. CPAP, bidirectional positive airway pressure, oxygen tubing and masks, percutaneous endoscopic gastrostomy tubes, endotracheal tubes, nasogastric tubes, pelvic binders, pulse oximetry probes, tracheostomy faceplates and ties, sequential compression devices, external fixators and limb mobilizers)Socioeconomic/LifestyleSmokingUnsafe home environmentInadequate foot wearInadequate hygieneLack of awareness for self-careFinancial insecurityChanges in routineCurrent ongoing adjunctive therapies integrated into care plan Medication reconciliation and their impact on wound healing reviewedPrescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, inhaled substances and nicotine replacement therapy)Medications that can affect healing include:chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosuppressive drugsOther medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics)Vitamin and mineral supplementationRecent blood work and other diagnostic test results reviewed and implictions for wound healing consideredDetermine bloodwork and other diagnostic tests required (see chart in guidelines)Ensure Albumin done during this time periodHome glycemic control and monitoring if diabetic17272099060Normal blood glucose ranges are needed for wound healing to occur00Normal blood glucose ranges are needed for wound healing to occurBS and A1C are within recommended range per responsible physician or NPEnsure Albumin/Urine creatinine ratio done during this time periodUse of glucose log book (Diabetes Passport)Adequate insulin suppliesGlucometer and required suppliesAssess for barriers in monitoring glycemic controlCommunity/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Diabetic Education ProgramPatient self-referral link professional referral link examination performedIdentify pressure points, contractures and areas of reddness (note if blanchable or non-blanchable)Evidence of previous pressure injuryUse of Braden Risk Scale Link: Pressure injury is below knee: assess potential to healBilateral lower leg assessment (LLA)completed31305595885ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies00ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies316230110490ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult needed00ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult neededComplete:ABPI/TPBI completed within last 3 mths and results documentedIf unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommendedRepeat ABPI/TPBI assessment every 3 months if healing is not progressingBilateral lower leg assessment that includes:Leg measurements (foot, ankle, calf, thigh) to assess edemaNail changes (thicker, dry, crumbly, presence of fungal infection)Assess interdigital spacesPresence of callous or cornsPresence of varicosities (varicose veins)Ankle flareDrainage on socksHistory of compressionWound and periwound assessment completed16891085090A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.00A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also plete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of woundStage pressure injuryAssess potential to healAssess need for debridementAssessment for infection (NERDS and STONEES)Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: to Waterloo Wellington Integrated Guidelines for Pressure Injuries: Pressure Ulcer Advisory Panel (NPUAP)Staging System (Updated April 2016)Stage 1Pressure Injury22606028575Non-blanchable erythema of intact skin00Non-blanchable erythema of intact skinIntact skin with a localized area of non-blanchable erythemaMay appear differently in darkly pigmented skinPresence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changesColour changes do not include purple or maroon discolouration; these may indicate deep tissue pressure injuryStage 2Pressure Injury23177552705Partial-thickness loss of skin with exposed dermis00Partial-thickness loss of skin with exposed dermisWound bed is viable, pink or red, moistMay also present as an intact or ruptured serum-filled blisterAdipose (fat) and deeper tissues are not visible ?Granulation tissue, slough and eschar are not present ?These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. ? This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions)Stage 3Pressure Injury247015934085Full-thickness skin loss00Full-thickness skin lossAdipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present Slough and/or eschar may be visible The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury Stage 4Pressure Injury24765049318Full-thickness skin and tissue loss00Full-thickness skin and tissue lossFull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injurySlough and/or eschar may be visible Epibole (rolled edges), undermining and/or tunneling often occur Depth varies by anatomical location If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure InjuryUnstageable Pressure Injury24765034290Obscured full-thickness skin and tissue loss00Obscured full-thickness skin and tissue lossExtent of tissue damage within the injury cannot be confirmed as it is obscured by slough or eschar If slough or eschar is removed a Stage 3 or Stage 4 pressure injury will be revealed Stable eschar (i.e. dry, adherent, intact without erythema or fluctuant) on an ischemic limb or the heel(s) should not be removedMedical Device RelatedPressure InjuryThis describes the etiology of the injuryResult from the use of devices designed and applied for diagnostic or therapeutic purposesResultant pressure injury generally conforms to the pattern or shape of the deviceInjury should be staged using the staging systemMucosal MembranePressure InjuryFound on mucous membranes with a history of medical device in use at the location of the injuryDue to the anatomy of the tissue these injuries cannot be stagedMoisture Associated Skin Damage (MASD) assessment completed07620MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.00MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.Assess continence of urine and stoolIf incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g. an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA)Skin assessment including skin foldsLink to RNAO Prompted Voiding Best Practice Guidelines management considered and initiated033655Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above00Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or aboveComplete:Brief Pain Inventory Short Form (BPI-SF)Identify type of pain Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin.Nociceptive pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Mild Opioids – e.g. CodeineStrong Opioids – e.g. Morphine or OxycodoneObtain physician/nurse practitioner orders for pharmaceutical treatments (opioids and non-opioids)Non-pharmacological pain control options (support surfaces, repositioning)Coordinate analgesic administration with wound care treatment timesPatient’s nutritional status optimized-338759266Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. 00Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. Calculate Body Mass Index (BMI)Determine recent weight loss/gainComplete Mini Nutritional Assessment (MNA) screening section results < 11 = complete assessment sectionIf assessment section results< 24 = Registered Dietician referral requiredRecent dietary consultIdentify barriers or risk factors to healthy eatingLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Wound etiology and appropriate pathway establishedIdentify initial cause of wound. Pressure injuries are localized injury to the skin and/or underlying tissue usually?over a bony prominence, as a result of pressure, or pressure in combination with?shearPatient and caregiver concerns and goals integrated into the care plan and shared with care team Complete: Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) formEnsure all patient/caregiver goals and concerns been addressedWound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) 42333189442When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.00When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.39582925195Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP order00Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP orderArrange for physician/nurse practitioner orders as required to begin plan of care including agreeance to professional referral recommendationsIdentify cause of pressureProvide pressure redistribution (support surfaces) for sleep, seating and use of medical devicesDebridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommendedEnsure appropriate skin careIdentify any potential barriers to wound treatment planIdentify appropriate footwear, offloading and repositioning optionsConsider required referals and further follow-up with previous professional referralsConsider compression if venous insufficiency/edema present and if APBI/TPBI is within safe rangeLink to Waterloo Wellington Venous Leg Guidelines – Compression: toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)Pressure RedistributionEnsure appropriate referrals for pressure redistribution have been arranged to qualified professionalsReview correct use of appropriate pressure redistribution devicesAssess need for support surface (chair/bed) Link to chart in guidelines: adherence to using appropriate pressure redistribution device(s)Assess barriers to appropriate pressure redistribution Initial and ongoing callous reduction is part of pressure redistributionAssess for secondary complications of offloading and refer concerns to treating practitionerLook for redmarks, blisters, skin abrasionsAsk about knee, hip or back issues (including contralateral limb) due to height difference of offloading deviceCheck for unsafe gait (are they stable, using appropriate aids, etc)Teach patient to assess for secondary complicationsCheck gait aids such as walker, cane, crutchesReview goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.)Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Patient counselled on the benefit of activity and rest for wound healing and comfort measuresRecent changes in overall activity levelDaily routine including continence concerns and/or access to bathroomPersonal assistance available to perform activities of daily livingDetermine where patient sleeps at night and sits during daySafety of transfersPressure distribution deviceConsider Occupational Therapist referral for pressure redistribution deviceAssess barriers to sleeping in bedAssess mobility and dexterity aids currently being used (bedrail, superpole, trapezebar, therapeutic surfaces, raised toilet set and sitting devices)Recommendations for exercise Patient/caregiver educational plan initiated-1693370908‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.00‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.Rest/ActivityTurning and sitting schedule for repositioningPillow between kneesSafetyPrevention of injury – friction, shearingWhen to call primary caregiver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)Pressure Relief/redistribution surfaceOffloading is required ‘for life’Understands need of debridementEncourage appropriate footwear to be worn at all times when weight bearing as discussed with foot care specialist Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and presence of wound drainageLifestyleSmoking and e-cigarette cessation with goal to be nicotene-freeGuidelines can be found at: managementWoundSelf care of woundDietaryDietary requirements as per dietician Blood glucose testing and recording in diaryLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Diagnostic TestsResults understood by patientDiagnostic testing (nutritional blood work and cholesterol levels)If diabetic, target ranges for A1C and blood sugar Skin CareWound self careHolistic self care of skin Incontinence and prevention/treatment of Moisture Associated Skin Damage (MASD)Community SupportsSeating clinic for wheelchairCommunity support groups (eg. Diabetic education and self- management sessions, walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)Link to Waterloo Wellington Diabetes Directory can be found at ____________________________Ability to self-manage optimizedReview for independence or need for ongoing assistance with the following:Barriers to participate (poor eyesight, physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)Decreased sensory perception affects ability to respond to pressure-related issuesReview importance and potential barriers to smoking cessation at every visit Pressure relief/redistributionAdequate hygiene skin exposed to moisture, perspirationDaily foot inspection with mirror(including bottom of foot and between toes)Ongoing footcare arrangedHome Environment – ADL’s Wound care NutritionCompression application and removal if prescribedLink to Waterloo Wellington Diabetes Directory can be found at obligationsSuggested website for review ____________________________Coping strategies implemented into plan of carePromoting independence to avoid practitioner/caregiver dependencyPatient’s concerns and fears (including practitioner dependence)Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)Family and caregiver support identified and incorporated into plan of careFamily/caregiver actively able to participate in treatment planRepositioning, nutrition, continence if neededImportance of caregiver respite/reliefSocial supports/community resources currently utilized is integrated into plan of careFamily support Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Ontario Disability Support Program –ODSP/Ontario Works, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Caregiver conflicts Long or short term placementConfirm that ongoing medication coverage is arrangedLink to Trillium Drug Benefits referrals are initiatedPrimary Care PhysicianCommunity NursingAdvanced Wound Specialist Nurse PractitionerOccupational TherapistUrologistInfectious Disease SpecialistVascular Surgeon Orthopedic SurgeonDermatologistPlastic SurgeonInternist/EndocrinologistNephrologistCardiologistOpthalmologist/OptometristMental Health SpecialistPsychologist/PsychiatristSocial worker Registered DietitianPharmacistNeurologistPhysiotherapistPhysiatristRegistered KinesiologistChiropodistDiabetic Education ProgramPatient self-referral link professional referral link PedorothistCertified OrthotistCertified ProsthetistPodiatristFootcare NurseLymphatic Massage TherapistCompression Stocking FitterOther___________________________Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendationsAppropriate documents sharedPressure mappingDiagnostic resultsIdentify need to reassess ABPI/TPBI in 6 monthsLower leg assessment resultsRecent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)Relevant consultation notesPost and current treatment and education planList of appropriate contact information for ongoing needsIf wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and teaching completed to:Referral source Most responsible physician (MRP)/nurse practitionerAcute careComplex Continuing Care/RehabLong-term careCommunity care Primary care physician/Nurse PractionerProfessionals referred to32385366395‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!00‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!Other _____________________________8-21 Days Expected OutcomesNotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patientDetermine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports availableIf Pressure injury is below knee: assess potential to healBilateral lower leg assessment (LLA)completed31305595885ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies00ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies316230110490ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult needed00ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult neededComplete:ABPI/TPBI completed within last 3 mths and results documentedIf unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommendedRepeat ABPI/TPBI assessment every 3 months if healing is not progressingBilateral lower leg assessment that includes:Leg measurements (foot, ankle, calf, thigh) to assess edemaNail changes (thicker, dry, crumbly, presence of fungal infection)Assess interdigital spacesPresence of callous or cornsPresence of varicosities (varicose veins)Ankle flareDrainage on socksHistory of compressionWound and periwound assessment completed143510119380A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.00A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also plete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of woundStage pressure injuryAssess potential to healAssess need for debridementAssessment for infection (NERDS and STONEES)Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: to Waterloo Wellington Integrated Guidelines for Pressure Injuries: treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) 1651050165When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.00When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.Arrange for physician/nurse practitioner orders as required including agreeance to professional referral recommendationsIdentify cause of pressureProvide pressure redistribution (support surfaces) for sleep, seating and use of medical devicesDebridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommendedEnsure appropriate skin careIdentify any potential barriers to wound treatment plan-332613085090Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP order00Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP orderIdentify appropriate footwear, offloading and repositioning optionsConsider required referals and further follow-up with previous professional referralsConsider compression if venous insufficiency/edema present and if APBI/TPBI is within safe rangeLink to Waterloo Wellington Venous Leg Guidelines – Compression: toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)Moisture Associated Skin Damage (MASD) assessment completed073660MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.00MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.Assess continence of urine and stoolIf incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g. an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA)Skin assessment including skin foldsLink to RNAO Prompted Voiding Best Practice Guidelines management considered and initiated254036195Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above00Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or aboveComplete:Brief Pain Inventory Short Form (BPI-SF)Identify type of pain Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin.Nociceptive pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Mild Opioids – e.g. CodeineStrong Opioids – e.g. Morphine or OxycodoneObtain physician/nurse practitioner orders for pharmaceutical treatments (opioids and non-opioids)Non-pharmacological pain control options (support surfaces, repositioning)Coordinate analgesic administration with wound care treatment timesPressure RedistributionEnsure appropriate referrals for pressure redistribution have been arranged to qualified professionalsReview correct use of appropriate pressure redistribution devicesAssess need for support surface (chair/bed) Link to chart in guidelines: adherence to using appropriate pressure redistribution device(s)Assess barriers to appropriate pressure redistribution Initial and ongoing callous reduction is part of pressure redistributionAssess for secondary complications of offloading and refer concerns to treating practitionerLook for redmarks, blisters, skin abrasionsAsk about knee, hip or back issues (including contralateral limb) due to height difference of offloading deviceCheck for unsafe gait (are they stable, using appropriate aids, etc)Teach patient to assess for secondary complicationsCheck gait aids such as walker, cane, crutchesReview goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.)Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)Medical/surgical history and co-morbidity management considered within care planReview for changesMedication reconciliation and their impact on wound healing reviewedReview for changes:Prescription, non-prescription, naturopathic and illicit drug useRecent blood work and other diagnostic test results reviewed and implictions for wound healing consideredDetermine bloodwork and other diagnostic tests required (see chart in guidelines)Home glycemic control and monitoring if diabetic17272099060Normal blood glucose ranges are needed for wound healing to occur00Normal blood glucose ranges are needed for wound healing to occurBS and A1C are within recommended range per responsible physician or NPUse of glucose log book (Diabetes Passport)Adequate insulin suppliesGlucometer and required suppliesAssess for barriers in monitoring glycemic controlCommunity/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Diabetic Education ProgramPatient self-referral link professional referral link ’s nutritional status optimized-338759266Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. 00Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. Calculate Body Mass Index (BMI)Determine recent weight loss/gainComplete Mini Nutritional Assessment (MNA) screening section results < 11 = complete assessment sectionIf assessment section results< 24 = Registered Dietician referral requiredRecent dietary consultIdentify barriers or risk factors to healthy eatingLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Patient and caregiver concerns and goals integrated into the care plan and shared with care teamReview for changes:Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) formEnsure all patient/caregiver goals and concerns been addressedPatient counselled on the benefit of activity and rest for wound healing and comfort measuresRecent changes in overall activity levelDaily routine including continence concerns and/or access to bathroomPersonal assistance available to perform activities of daily livingDetermine where patient sleeps at night and sits during daySafety of transfersPressure distribution device Consider Occupational Therapist referral for pressure redistribution deviceAssess barriers to sleeping in bedAssess mobility and dexterity aids currently being used (bedrail, superpole, trapezebar, therapeutic surfaces, raised toilet set and sitting devices)Recommendations for exercise Patient/caregiver educational plan -2540037042‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.00‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.Rest/ActivityTurning and sitting schedule for repositioningPillow between kneesSafetyPrevention of injury – friction, shearingWhen to call primary caregiver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)Pressure Relief/redistribution surfaceOffloading is required ‘for life’Understands need of debridementEncourage appropriate footwear to be worn at all times when weight bearing as discussed with foot care specialist Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and presence of wound drainageLifestyleSmoking and e-cigarette cessation with goal to be nicotene-freeGuidelines can be found at: managementWoundSelf care of woundDietaryDietary requirements as per dietician Blood glucose testing and recording in diaryLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Diagnostic TestsResults understood by patientDiagnostic testing (nutritional blood work and cholesterol levels)If diabetic, target ranges for A1C and blood sugar Skin CareWound self careHolistic self care of skin Incontinence and prevention/treatment of Moisture Associated Skin Damage (MASD)Community SupportsSeating clinic for wheelchairCommunity support groups (eg. Diabetic education and self- management sessions, walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)Link to Waterloo Wellington Diabetes Directory can be found at ____________________________Ability to self-manage optimizedReview for independence or need for ongoing assistance with the following:Barriers to participate (poor eyesight, physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)Decreased sensory perception affects ability to respond to pressure-related issuesReview importance and potential barriers to smoking cessation at every visit Pressure relief/redistributionAdequate hygiene skin exposed to moisture, perspirationDaily foot inspection with mirror(including bottom of foot and between toes)Ongoing footcare arrangedHome Environment – ADL’s Wound care NutritionCompression application and removal if prescribedLink to Waterloo Wellington Diabetes Directory can be found at obligationsSuggested website for review ____________________________Coping strategies implemented into plan of carePromoting independence to avoid practitioner/caregiver dependencyPatient’s concerns and fears (including practitioner dependence)Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Family and caregiver support identified and incorporated into plan of careFamily/caregiver actively able to participate in treatment planRepositioning, nutrition, continence if neededImportance of caregiver respite/relief Social supports/community resources currently utilized is integrated into plan of careFamily support Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Ontario Disability Support Program –ODSP/Ontario Works, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Caregiver conflicts Long or short term placementConfirm that ongoing medication coverage is arrangedLink to Trillium Drug Benefits referrals are initiatedPrimary Care PhysicianCommunity NursingAdvanced Wound Specialist Nurse PractitionerOccupational TherapistUrologistInfectious Disease SpecialistVascular Surgeon Orthopedic SurgeonDermatologistPlastic SurgeonInternist/EndocrinologistNephrologistCardiologistOpthalmologist/OptometristMental Health SpecialistPsychologist/PsychiatristSocial worker Registered DietitianPharmacistNeurologistPhysiotherapistPhysiatristRegistered KinesiologistChiropodistDiabetic Education ProgramPatient self-referral link professional referral link PedorothistCertified OrthotistCertified ProsthetistPodiatristFootcare NurseLymphatic Massage TherapistCompression Stocking FitterOther___________________________Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendationsAppropriate documents sharedPressure mappingDiagnostic resultsIdentify need to reassess ABPI/TPBI in 6 monthsLower leg assessment resultsRecent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)Relevant consultation notesPost and current treatment and education planList of appropriate contact information for ongoing needsIf wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and teaching completed to:Referral source 3400425-5080‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!00‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!Most responsible physician (MRP)/nurse practitionerAcute careComplex Continuing Care/RehabLong-term careCommunity care Primary care physician/Nurse PractionerProfessionals referred toOther _____________________________ 21-28 Days Expected Outcomes (Ongoing to day 76)NotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patientDetermine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports availableIf Pressure injury is below knee: assess potential to healBilateral lower leg assessment (LLA)completed31305595885ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies00ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies316230110490ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult needed00ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult neededComplete:ABPI/TPBI completed within last 3 mths and results documentedIf unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommendedRepeat ABPI/TPBI assessment every 3 months if healing is not progressingBilateral lower leg assessment that includes:Leg measurements (foot, ankle, calf, thigh) to assess edemaNail changes (thicker, dry, crumbly, presence of fungal infection)Assess interdigital spacesPresence of callous or cornsPresence of varicosities (varicose veins)Ankle flareDrainage on socksHistory of compressionWound and periwound assessment completed143510119380A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan should include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.00A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan should include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also plete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of woundStage pressure injuryAssess potential to healAssess need for debridementAssessment for infection (NERDS and STONEES)Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: to Waterloo Wellington Integrated Guidelines for Pressure Injuries: treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) 1651050165When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.00When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.Arrange for physician/nurse practitioner orders as required including agreeance to professional referral recommendationsIdentify cause of pressureProvide pressure redistribution (support surfaces) for sleep, seating and use of medical devicesDebridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommendedEnsure appropriate skin careIdentify any potential barriers to wound treatment plan-330962080645Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP order00Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP orderIdentify appropriate footwear, offloading and repositioning optionsConsider required referals and further follow-up with previous professional referralsConsider compression if venous insufficiency/edema present and if APBI/TPBI is within safe rangeLink to Waterloo Wellington Venous Leg Guidelines – Compression: toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)Moisture Associated Skin Damage (MASD) assessment completed073660MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.00MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.Assess continence of urine and stoolIf incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g. an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA)Skin assessment including skin foldsLink to RNAO Prompted Voiding Best Practice Guidelines management considered and initiated033655Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above00Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or aboveComplete:Brief Pain Inventory Short Form (BPI-SF)Identify type of pain Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin.Nociceptive pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Mild Opioids – e.g. CodeineStrong Opioids – e.g. Morphine or OxycodoneObtain physician/nurse practitioner orders for pharmaceutical treatments (opioids and non-opioids)Non-pharmacological pain control options (support surfaces, repositioning)Coordinate analgesic administration with wound care treatment timesPressure RedistributionEnsure appropriate referrals for pressure redistribution have been arranged to qualified professionalsReview correct use of appropriate pressure redistribution devicesAssess need for support surface (chair/bed) Link to chart in guidelines: adherence to using appropriate pressure redistribution device(s)Assess barriers to appropriate pressure redistribution Initial and ongoing callous reduction is part of pressure redistributionAssess for secondary complications of offloading and refer concerns to treating practitionerLook for redmarks, blisters, skin abrasionsAsk about knee, hip or back issues (including contralateral limb) due to height difference of offloading deviceCheck for unsafe gait (are they stable, using appropriate aids, etc)Teach patient to assess for secondary complicationsCheck gait aids such as walker, cane, crutchesReview goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.)Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)Medical/surgical history and co-morbidity management considered within care planReview for changesMedication reconciliation and their impact on wound healing reviewedReview for changes:Prescription, non-prescription, naturopathic and illicit drug useRecent blood work and other diagnostic test results reviewed and implictions for wound healing consideredDetermine bloodwork and other diagnostic tests required (see chart in guidelines)Home Glycemic Control and Monitoring if diabetic17272099060Normal blood glucose ranges are needed for wound healing to occur00Normal blood glucose ranges are needed for wound healing to occurBS and A1C are within recommended range per responsible physician or NPUse of glucose log book (Diabetes Passport)Adequate insulin suppliesGlucometer and required suppliesAssess for barriers in monitoring glycemic controlPatient’s nutritional status optimized-338759266Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. 00Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. Calculate Body Mass Index (BMI)Determine recent weight loss/gainComplete Mini Nutritional Assessment (MNA) screening section results < 11 = complete assessment sectionIf assessment section results< 24 = Registered Dietician referral requiredRecent dietary consultIdentify barriers or risk factors to healthy eatingLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Patient and caregiver concerns and goals integrated into the care plan and shared with care teamReview for changes:Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) formEnsure all patient/caregiver goals and concerns been addressedPatient counselled on the benefit of activity and rest for comfort measures and wound healingRecent changes in overall activity levelDaily routine including continence concerns and/or access to bathroomPersonal assistance available to perform activities of daily livingDetermine where patient sleeps at night and sits during daySafety of transfersPressure relief device &/or redistributionAssess barriers to sleeping in bedAssess mobility and dexterity aids currently being used (bedrail, superpole, trapezebar, airbed)Recommendations for exercise Consider Occupational Therapist referral for pressure relief devicePatient/caregiver educational plan continued13398548260‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.00‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.Rest/ActivityTurning and sitting schedule for repositioningPillow between kneesSafetyPrevention of injury – friction, shearingWhen to call primary caregiver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)Pressure Relief/redistribution surfaceOffloading is required ‘for life’Understands need of debridementEncourage appropriate footwear to be worn at all times when weight bearing as discussed with foot care specialist Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and presence of wound drainageLifestyleSmoking and e-cigarette cessation with goal to be nicotene-freeGuidelines can be found at: managementWoundSelf care of woundDietaryDietary requirements as per dietician Blood glucose testing and recording in diaryLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Diagnostic TestsResults understood by patientDiagnostic testing (nutritional blood work and cholesterol levels)If diabetic, target ranges for A1C and blood sugar Skin CareWound self careHolistic self care of skin Incontinence and prevention/treatment of Moisture Associated Skin Damage (MASD)Community SupportsSeating clinic for wheelchairCommunity support groups (eg. Diabetic education and self- management sessions, walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)Link to Waterloo Wellington Diabetes Directory can be found at ____________________________Ability to self-manage optimizedReview for independence or need for ongoing assistance with the following:Barriers to participate (poor eyesight, physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)Decreased sensory perception affects ability to respond to pressure-related issuesReview importance and potential barriers to smoking cessation at every visit Pressure relief/redistributionAdequate hygiene skin exposed to moisture, perspirationDaily foot inspection with mirror(including bottom of foot and between toes)Ongoing footcare arrangedHome Environment – ADL’s Wound care NutritionCompression application and removal if prescribedLink to Waterloo Wellington Diabetes Directory can be found at obligationsSuggested website for review ____________________________Coping strategies implemented into plan of carePromoting independence to avoid practitioner/caregiver dependencyPatient’s concerns and fears (including practitioner dependence)Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Family and caregiver support identified and incorporated into plan of careFamily/caregiver actively able to participate in treatment planRepositioning, nutrition, continence if neededImportance of caregiver respite/reliefSocial supports/community resources currently utilized is integrated into plan of careFamily support Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Ontario Disability Support Program –ODSP/Ontario Works, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Caregiver conflicts Long or short term placementConfirm that ongoing medication coverage is arrangedLink to Trillium Drug Benefits referrals are initiatedPrimary Care PhysicianCommunity NursingAdvanced Wound Specialist Nurse PractitionerOccupational TherapistUrologistInfectious Disease SpecialistVascular Surgeon Orthopedic SurgeonDermatologistPlastic SurgeonInternist/EndocrinologistNephrologistCardiologistOpthalmologist/OptometristMental Health SpecialistPsychologist/PsychiatristSocial worker Registered DietitianPharmacistNeurologistPhysiotherapistPhysiatrist Registered KinesiologistChiropodistDiabetic Education ProgramPatient self-referral link professional referral link PedorothistCertified OrthotistCertified ProsthetistPodiatristFootcare NurseLymphatic Massage TherapistCompression Stocking FitterOther___________________________Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendationsAppropriate documents sharedPressure mappingDiagnostic resultsIdentify need to reassess ABPI/TPBI in 6 monthsLower leg assessment resultsRecent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)Relevant consultation notesPost and current treatment and education planList of appropriate contact information for ongoing needsIf wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and teaching completed to:Referral source Most responsible physician (MRP)/nurse practitionerAcute careComplex Continuing Care/RehabLong-term careCommunity care Primary care physician/Nurse PractionerProfessionals referred to32385433070‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!00‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!Other _____________________________77-84 Days Expected Outcomes (Ongoing to day 90)NotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patientDetermine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports availableIf Pressure injury is below knee: assess potential to healBilateral lower leg assessment (LLA)completed31305595885ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies00ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies316230110490ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult needed00ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult neededComplete:ABPI/TPBI completed within last 3 mths and results documentedIf unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies is recommendedRepeat ABPI/TPBI assessment every 3 months if healing is not progressingBilateral lower leg assessment that includes:Leg measurements (foot, ankle, calf, thigh) to assess edemaNail changes (thicker, dry, crumbly, presence of fungal infection)Assess interdigital spacesPresence of callous or cornsPresence of varicosities (varicose veins)Ankle flareDrainage on socksHistory of compressionWound and periwound assessment completed143510119380A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan should include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.00A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan should include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also plete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of woundStage pressure injuryAssess potential to healReview etiology and consider biopsy if not healingAssess need for debridementAssessment for infection (NERDS and STONEES)Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: to Waterloo Wellington Integrated Guidelines for Pressure Injuries: treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) 1651047625When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.00When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.Arrange for physician/nurse practitioner orders as required including agreeance to professional referral recommendationsIdentify cause of pressureProvide pressure redistribution (support surfaces) for sleep, seating and use of medical devicesDebridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommendedEnsure appropriate skin careIdentify any potential barriers to wound treatment plan-330962067945Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP order00Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP orderIdentify appropriate footwear, offloading and repositioning optionsConsider required referals and further follow-up with previous professional referralsConsider compression if venous insufficiency/edema present and if APBI/TPBI is within safe rangeLink to Waterloo Wellington Venous Leg Guidelines – Compression: toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)-40005294005MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.00MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.Moisture Associated Skin Damage (MASD) assessment completedAssess continence of urine and stoolIf incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g. an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA)Skin assessment including skin foldsLink to RNAO Prompted Voiding Best Practice Guidelines management considered and initiated033655Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above00Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or aboveComplete:Brief Pain Inventory Short Form (BPI-SF)Identify type of pain Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin.Nociceptive pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Mild Opioids – e.g. CodeineStrong Opioids – e.g. Morphine or OxycodoneObtain physician/nurse practitioner orders for pharmaceutical treatments (opioids and non-opioids)Non-pharmacological pain control options (support surfaces, repositioning)Coordinate analgesic administration with wound care treatment timesPressure RedistributionEnsure appropriate referrals for pressure redistribution have been arranged to qualified professionalsReview correct use of appropriate pressure redistribution devicesAssess need for support surface (chair/bed) Link to chart in guidelines: adherence to using appropriate pressure redistribution device(s)Assess barriers to appropriate pressure redistribution Initial and ongoing callous reduction is part of pressure redistributionAssess for secondary complications of offloading and refer concerns to treating practitionerLook for redmarks, blisters, skin abrasionsAsk about knee, hip or back issues (including contralateral limb) due to height difference of offloading deviceCheck for unsafe gait (are they stable, using appropriate aids, etc)Teach patient to assess for secondary complicationsCheck gait aids such as walker, cane, crutchesReview goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.)Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Medical/surgical history and co-morbidity management considered within care planReview for changesMedication reconciliation and their impact on wound healing reviewedReview for changes:Prescription, non-prescription, naturopathic and illicit drug useRecent blood work and other diagnostic test results reviewed and implictions for wound healing consideredDetermine bloodwork and other diagnostic tests required (see chart in guidelines)Home Glycemic Control and Monitoring if diabetic17272099060Normal blood glucose ranges are needed for wound healing to occur00Normal blood glucose ranges are needed for wound healing to occurBS and A1C are within recommended range per responsible physician or NPUse of glucose log book (Diabetes Passport)Adequate insulin suppliesGlucometer and required suppliesAssess for barriers in monitoring glycemic controlPatient’s nutritional status optimized-338759266Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. 00Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. Calculate Body Mass Index (BMI)Determine recent weight loss/gainComplete Mini Nutritional Assessment (MNA) screening section results < 11 = complete assessment sectionIf assessment section results< 24 = Registered Dietician referral requiredRecent dietary consultIdentify barriers or risk factors to healthy eatingLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Patient and caregiver concerns and goals integrated into the care plan and shared with care teamReview for changes:Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) formEnsure all patient/caregiver goals and concerns been addressedPatient counselled on the benefit of activity and rest for comfort measures and wound healingRecent changes in overall activity levelDaily routine including continence concerns and/or access to bathroomPersonal assistance available to perform activities of daily livingDetermine where patient sleeps at night and sits during daySafety of transfersPressure relief device &/or redistributionAssess barriers to sleeping in bedAssess mobility and dexterity aids currently being used (bedrail, superpole, trapezebar, airbed)Recommendations for exercise Consider Occupational Therapist referral for pressure relief devicePatient/caregiver educational plan continued133985124460‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.00‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.Rest/ActivityTurning and sitting schedule for repositioningPillow between kneesSafetyPrevention of injury – friction, shearingWhen to call primary caregiver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)Pressure Relief/redistribution surfaceOffloading is required ‘for life’Understands need of debridementEncourage appropriate footwear to be worn at all times when weight bearing as discussed with foot care specialist Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and presence of wound drainageLifestyleSmoking and e-cigarette cessation with goal to be nicotene-freeGuidelines can be found at: managementWoundSelf care of woundDietaryDietary requirements as per dietician Blood glucose testing and recording in diaryLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Diagnostic TestsResults understood by patientDiagnostic testing (nutritional blood work and cholesterol levels)If diabetic, target ranges for A1C and blood sugar Skin CareWound self careHolistic self care of skin Incontinence and prevention/treatment of Moisture Associated Skin Damage (MASD)Community SupportsSeating clinic for wheelchairCommunity support groups (eg. Diabetic education and self- management sessions, walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)Link to Waterloo Wellington Diabetes Directory can be found at ____________________________Ability to self-manage optimizedReview for independence or need for ongoing assistance with the following:Barriers to participate (poor eyesight, physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)Decreased sensory perception affects ability to respond to pressure-related issuesReview importance and potential barriers to smoking cessation at every visit Pressure relief/redistributionAdequate hygiene skin exposed to moisture, perspirationDaily foot inspection with mirror(including bottom of foot and between toes)Ongoing footcare arrangedHome Environment – ADL’s Wound care NutritionCompression application and removal if prescribedLink to Waterloo Wellington Diabetes Directory can be found at obligationsSuggested website for review ____________________________Coping strategies implemented into plan of carePromoting independence to avoid practitioner/caregiver dependencyPatient’s concerns and fears (including practitioner dependence)Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Family and caregiver support identified and incorporated into plan of careFamily/caregiver actively able to participate in treatment planRepositioning, nutrition, continence if neededImportance of caregiver respite/relief Social supports/community resources currently utilized is integrated into plan of careFamily support Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Ontario Disability Support Program –ODSP/Ontario Works, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Caregiver conflicts Long or short term placementConfirm that ongoing medication coverage is arrangedLink to Trillium Drug Benefits referrals are initiatedPrimary Care PhysicianCommunity NursingAdvanced Wound Specialist Nurse PractitionerOccupational TherapistUrologistInfectious Disease SpecialistVascular Surgeon Orthopedic SurgeonDermatologistPlastic SurgeonInternist/EndocrinologistNephrologistCardiologistOpthalmologist/OptometristMental Health SpecialistPsychologist/PsychiatristSocial worker Registered DietitianPharmacistNeurologistPhysiotherapistPhysiatristRegistered KinesiologistChiropodistDiabetic Education ProgramPatient self-referral link professional referral link PedorothistCertified OrthotistCertified ProsthetistPodiatristFootcare NurseLymphatic Massage TherapistCompression Stocking FitterOther___________________________Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendationsAppropriate documents sharedPressure mappingDiagnostic resultsIdentify need to reassess ABPI/TPBI in 6 monthsLower leg assessment resultsRecent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)Relevant consultation notesPost and current treatment and education planList of appropriate contact information for ongoing needsIf wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and teaching completed to:Referral source Most responsible physician (MRP)/nurse practitionerAcute careComplex Continuing Care/RehabLong-term careCommunity care Primary care physician/Nurse PractionerProfessionals referred to32385375920‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!00‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!Other _____________________________91-98 Days Expected OutcomesNotesMost Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Communication with primary care physician and/or Nurse Practioner to update on any significant changes in patient’s condition.Refer patient to ‘Care Connects’ if no responsible practioner currently involved with patientDetermine if MRP/NP is part of family health team (FHT) or community health centre (CHC) and consider additional supports availableIf Pressure injury is below knee: assess potential to healBilateral lower leg assessment (LLA)completed31305595885ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies00ABPI 0.5 to 0.8 TPBI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies316230110490ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult needed00ABPI <0.5 TPBI <0.64 Urgent vascular surgical consult neededComplete:ABPI/TPBI completed within last 3 mths and results documentedIf unable to obtain ABPI/TPBI, referral to medical imaging for vascular studies (arterial segmented pressures) is recommendedRepeat ABPI/TPBI assessment every 3 months if healing is not progressingBilateral lower leg assessment that includes:Leg measurements (foot, ankle, calf, thigh) to assess edemaNail changes (thicker, dry, crumbly, presence of fungal infection)Assess interdigital spacesPresence of callous or cornsPresence of varicosities (varicose veins)Ankle flareDrainage on socksHistory of compressionWound and periwound assessment completed143510119380A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also recommended.00A pressure injury with adequate vascular supply, pressure distribution & receiving treatment per best practice should show signs of healing within two to four weeks. When pressure injuries are not progressing towards closure (20-30%) treatment plan may include the initiation of a two-week trial of topical antimicrobials. An assessment by a wound care specialist is also plete: Bates-Jensen Wound Assessment Tool (BWAT) OR Pressure Ulcer Scale for Healing (PUSH) Measure and document size of woundStage pressure injuryAssess potential to healAssess potential to healReview etiology and consider biopsy if not healingAssess need for debridementAssessment for infection (NERDS and STONEES)Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: to Waterloo Wellington Integrated Guidelines for Pressure Injuries: treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) 1651050165When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.00When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.Arrange for physician/nurse practitioner orders as required including agreeance to professional referral recommendationsIdentify cause of pressureProvide pressure redistribution (support surfaces) for sleep, seating and use of medical devicesDebridement/reduction by qualified professional Re-visit to pressure redistribution professional is recommendedEnsure appropriate skin care-330962060960Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP order00Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TPBIs to be determined and results evaluated in addition to physician/NP orderIdentify any potential barriers to wound treatment planIdentify appropriate footwear, offloading and repositioning optionsConsider required referals and further follow-up with previous professional referralsConsider compression if venous insufficiency/edema present and if APBI/TPBI is within safe rangeLink to Waterloo Wellington Venous Leg Guidelines – Compression: toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)Moisture Associated Skin Damage (MASD) assessment completed073660MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.00MASD can be defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.Assess continence of urine and stoolIf incontinence is a concern, a continence assessment should be completed by a qualified practioner (e.g. an Enterstomal Therapist (ET) or Nurse Continence Advisor (NCA)Skin assessment including skin foldsLink to RNAO Prompted Voiding Best Practice Guidelines management considered and initiated033655Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or above00Pain Red Flags Possible InfectionIncrease in pain level (new pain in patients with altered sensation )Possible Arterial InvolvementPain on walking (caused by intermittent claudication)Pain with elevation of lower limbs Rest pain Nocturnal pain Pain can be a trigger for autonomic dysreflexia that may occur in patients with spinal cord injury T6 or aboveComplete:Brief Pain Inventory Short Form (BPI-SF)Identify type of pain Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia – sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents – e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin.Nociceptive pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids – e.g. ASA or Acetaminophen Mild Opioids – e.g. CodeineStrong Opioids – e.g. Morphine or OxycodoneObtain physician/nurse practitioner orders for pharmaceutical treatments (opioids and non-opioids)Non-pharmacological pain control options (support surfaces, repositioning)Coordinate analgesic administration with wound care treatment timesPressure RedistributionEnsure appropriate referrals for pressure redistribution have been arranged to qualified professionalsReview correct use of appropriate pressure redistribution devicesAssess need for support surface (chair/bed) Link to chart in guidelines: adherence to using appropriate pressure redistribution device(s)Assess barriers to appropriate pressure redistribution Initial and ongoing callous reduction is part of pressure redistributionAssess for secondary complications of offloading and refer concerns to treating practitionerLook for redmarks, blisters, skin abrasionsAsk about knee, hip or back issues (including contralateral limb) due to height difference of offloading deviceCheck for unsafe gait (are they stable, using appropriate aids, etc)Teach patient to assess for secondary complicationsCheck gait aids such as walker, cane, crutchesReview goals of pressure redistribution (i.e. transition from cast to shoes, foot orthoses, etc.)Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Assistive Devices Program (ADP), Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)Medical/surgical history and co-morbidity management considered within care planReview for changesMedication reconciliation and their impact on wound healing reviewedReview for changes:Prescription, non-prescription, naturopathic and illicit drug useRecent blood work and other diagnostic test results reviewed and implictions for wound healing consideredDetermine bloodwork and other diagnostic tests required (see chart in guidelines)Home Glycemic Control and Monitoring if diabetic17272099060Normal blood glucose ranges are needed for wound healing to occur00Normal blood glucose ranges are needed for wound healing to occurBS and A1C are within recommended range per responsible physician or NPUse of glucose log book (Diabetes Passport)Adequate insulin suppliesGlucometer and required suppliesAssess for barriers in monitoring glycemic controlPatient’s nutritional status optimized-338759266Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. 00Nutrition is an essential component of wound healing. Consider dietician referral for supplementation recommmendations. Calculate Body Mass Index (BMI)Determine recent weight loss/gainComplete Mini Nutritional Assessment (MNA) screening section results < 11 = complete assessment sectionIf assessment section results< 24 = Registered Dietician referral requiredRecent dietary consultIdentify barriers or risk factors to healthy eatingLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Patient and caregiver concerns and goals integrated into the care plan and shared with care teamReview for changes:Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) formEnsure all patient/caregiver goals and concerns been addressedPatient counselled on the benefit of activity and rest for comfort measures and wound healingRecent changes in overall activity levelDaily routine including continence concerns and/or access to bathroomPersonal assistance available to perform activities of daily livingDetermine where patient sleeps at night and sits during daySafety of transfersPressure relief device &/or redistributionAssess barriers to sleeping in bedAssess mobility and dexterity aids currently being used (bedrail, superpole, trapezebar, airbed)Recommendations for exercise Consider Occupational Therapist referral for pressure relief devicePatient/caregiver educational plan continued8318528575‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.00‘Teach-back’ method is a way of ascertaining patients understanding about what they need to know or do regarding their health. Patients are asked to state in their own words what they understand to be important. It is a way to confirm that things have been explained in a manner that the patient understands.Rest/ActivityTurning and sitting schedule for repositioningPillow between kneesSafetyPrevention of injury – friction, shearingWhen to call primary caregiver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow, difficulties with compression)Pressure Relief/redistribution surfaceOffloading is required ‘for life’Understands need of debridementEncourage appropriate footwear to be worn at all times when weight bearing as discussed with foot care specialist Examination of footwear, orthotics and offloading devices for foreign objects, wear pattern, pressure points and presence of wound drainageLifestyleSmoking and e-cigarette cessation with goal to be nicotene-freeGuidelines can be found at: managementWoundSelf care of woundDietaryDietary requirements as per dietician Blood glucose testing and recording in diaryLink to EatRight Ontario to talk to dieticianeatrightontario.ca 1-877-510-5102Diagnostic TestsResults understood by patientDiagnostic testing (nutritional blood work and cholesterol levels)If diabetic, target ranges for A1C and blood sugar Skin CareWound self careHolistic self care of skin Incontinence and prevention/treatment of Moisture Associated Skin Damage (MASD)Community SupportsSeating clinic for wheelchairCommunity support groups (eg. Diabetic education and self- management sessions, walking groups, Southern Ontario Aboriginal Diabetes Initiative - SOADI)Link to Waterloo Wellington Diabetes Directory can be found at ____________________________Ability to self-manage optimizedReview for independence or need for ongoing assistance with the following:Barriers to participate (poor eyesight, physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)Decreased sensory perception affects ability to respond to pressure-related issuesReview importance and potential barriers to smoking cessation at every visit Pressure relief/redistributionAdequate hygiene skin exposed to moisture, perspirationDaily foot inspection with mirror(including bottom of foot and between toes)Ongoing footcare arrangedHome Environment – ADL’s Wound care NutritionCompression application and removal if prescribedLink to Waterloo Wellington Diabetes Directory can be found at obligationsSuggested website for review ____________________________Coping strategies implemented into plan of carePromoting independence to avoid practitioner/caregiver dependencyPatient’s concerns and fears (including practitioner dependence)Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form –GDS15 Suicide assessment if applicable ETOH and illicit/recreational drug use Check for availability for financial compensation (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program –ODSP, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)Family and caregiver support identified and incorporated into plan of careFamily/caregiver actively able to participate in treatment planRepositioning, nutrition, continence if neededImportance of caregiver respite/reliefSocial supports/community resources currently utilized is integrated into plan of careFamily support Check for availability for financial compensation (e.g. private insurance, veterans medical benefits, Ontario Disability Support Program –ODSP/Ontario Works, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit) Community/health resourcesLink to Waterloo Wellington Diabetes Directory can be found at Caregiver conflicts Long or short term placementConfirm that ongoing medication coverage is arrangedLink to Trillium Drug Benefits referrals are initiatedPrimary Care PhysicianCommunity NursingAdvanced Wound Specialist Nurse PractitionerOccupational TherapistUrologistInfectious Disease SpecialistVascular Surgeon Orthopedic SurgeonDermatologistPlastic SurgeonInternist/EndocrinologistNephrologistCardiologistOpthalmologist/OptometristMental Health SpecialistPsychologist/PsychiatristSocial worker Registered DietitianPharmacistNeurologistPhysiotherapistPhysiatristRegistered KinesiologistChiropodistDiabetic Education ProgramPatient self-referral link professional referral link PedorothistCertified OrthotistCertified ProsthetistPodiatristFootcare NurseLymphatic Massage TherapistCompression Stocking FitterOther___________________________Physician/nurse practitioner orders received as required to change plan of care including agreeance to professional referral recommendationsAppropriate documents sharedPressure mappingDiagnostic resultsIdentify need to reassess ABPI/TPBI in 6 monthsLower leg assessment resultsRecent vascular study results (eg. ABPI, TPBI, Transcutaneous Oxygen Pressure(TcPo2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies)Relevant consultation notesPost and current treatment and education planList of appropriate contact information for ongoing needsIf wound closed or eschar is stable (in arterial disease) send discharge summary outlining outstanding issues and teaching completed to:Referral source Most responsible physician (MRP)/nurse practitionerAcute careComplex Continuing Care/RehabLong-term careCommunity care Primary care physician/Nurse PractionerProfessionals referred to32385175895‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!00‘Closed’ vs ‘Healed’Closed : Skin intact, underlying tissue or structures are not visibleHealed : Wound has been closed for a 2 year time period allowing for collagen re-modelling from type 3 to type 1These terms are often mistakenly used interchangeably.Understand and teach the difference!Other _____________________________ ................
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