Wound Management Plan 1 for Post-Operative Knee Replacement Infection

Wound Management Plan 1
Reason for this admission : The patient has undergone total knee replecament and
is suffering frompost operative wound infection
Name of patient: Mr. Noel Frost
Age: 65 years
Social History: Has a wife and two daughthers (married) and 5 grandchidren.
Occupation: Retired civil engineer who has been working a senior lecturer
Cognition: correct orientation to time and place
Principle diagnosis: osteoasrthritis
Medical History: osteoarthritis, hypertension, , Type 1 diabetes
Type of Wounds: wound in knee
Dressings: At right knee with crepe bandage, kept intact
Diet: through IV in the wrist
Elimination: 12 times a day
Mobility (pre-admission): 2 wheel-walker (around the house), crutches & WC
(outside house)
 ADLs: Top half (100% independent)
Lower half (70% independent)
FOR OFFICIAL USE ONLY Holmesglen: fd/nursing æOct-2018 Delivery & 2\HLTENN006 - Apply principles of wound management\New Assessment 201 Mssessment Task 1-
Simple Wound\Wound Management chart.d00(

(5 z
z
WOUND CARE ASSESSMENT &
PLAN
Only One (1) Wound Per Form —
Circle or tick responses as appropriate
Legend for Wound Stages Location (circle site on
Stage Skin Integrity Appearance Exudate
Intact/Non Blanchable Erythema or Discolouratjon None
2 Superficial Loss Erythema, hot, painful or
oedematous Low / Mod
3 Loss of B/c tissue wit) cavity Sloughy, Necrotic, Red Low / Mod i High
4 Loss of s/c tissue with cavity, Red
Sloughy, Necrotic,
involving bone, muscle or tendon
Low / Mod / High
Unstageable Loss of tissue with cavitv,
unab'e to view base of wauhd Slough, Necrotic, Red Low / Mod i High
Suspected
Deep [6)
Intact but suspected to have
deep tissue involvement
Intact, Discoloured or blood
filled blister None
WOUND TYPE:Pressure injurya Burn Arterial ulcer
Venous ulcerMalignant Haematoma Diabetic ulcer
LacerationAbrasion Surgical Incision
BlistersSkin Tear a Omer
Date: Time: Date: Time: Time:
Dimensions: 4incles
10 inches Widdi
Depth
Length
cm
cm cm
cm
cm
cm
Stage:
Photograph:
Consent obtained Yes / No
Photograph Yes / No Photograph Yes No Photograph
Wound Swabs: Wound Swab Yes / No Wound Swab Yes / No Wound Swab
Results of swabs:
Nurse Review: Nurse Review Yes / No I Nurse Review No Nurse Review
Duration of Wound:
mths = Months
< 3 mths / 3-6 mths /
6-12 mths / 12+ mfrs
< 3 mths f 3-6 /
6-12 mths / 12+ mths
< 3 mths / 3-6 mths /
6-12 mths / 12+ mths
baldate: Amount:
Type:
a Nil a Mod Q
Heavy
a Low a
Mod Heavy Low a
Mod Heavy
Serous Purulent
Haemoserous
C) Serous a Purulent
Haemoserous
a Serous Pun.]lent C.I
Haemoserous
Drains Insitu
Odour: Q Offensive NÉE I C) Offensive Nil Offensive Nil
Colour of Wound and
Surrounds
colour a Pink
epitheiisation Cl Red -
granulating
Yellow - slough
Green - infectious
Black -necrosis
Colour (Tick)
Pink - epithetisation
Red granulating
Yellow -
slough Green
- infectious
aack -
necrosis
Colour (Tick)
Pink - epitheiisation
a Red - granulating
Yellow - slough
Green - infectious
Black -necrosis
Surrounding skin: Healthy
fragile O Macerated
Inflamed Q Discoioured
Other
Heatthy Dry/Scaly
Fragile Q Macerated
Inflamed Discoloured
Other
Healthy C] Dry/Scaly Fragile
Macerated inflamed
Discotoured
Cl Other
Suture Line: jaggered Q Clips / Sutures insitu Clips / Sutures insitu a Clips / Sutures insitu
Present on admission:
Comments:
Pain on dressing change
Severity Score (Score 1-
10): 3
RN Printed Name:
RN Signature:
Intermittent Intermittent