Topical Negative Pressure

Transcription

1 Accessible, Responsive Community Healthcare South Birmingham Community Health Adults and Community Division Topical Negative Pressure Wound Assessment and Plan of Care Document

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3 Topical Negative Pressure (TNP) Therapy Wound Assessment & Plan of Care Patient Details: (sticker) Site / type: TNP commenced: Record of Wound Assessment and Dressing Changes : Size: Diameter Length Depth Undermining Photograph Appearance: Sloughy Granulating Over granulating Other Surrounding skin: Colour Oedematous Celluitic Dry / eczema Maceration Analgesics: Regular For dressings only Dressings: Size of sponge / gauze Setting: Pressure applied Continuous or Intermittent Exudate: Colour Odour Quantity Canister Change Infection: Investigations Antibiotics Serum Albumin Waterlow Assessed by:

4 Record of Checks (complete every shift) Night Late Early Record of Canister Changes and Exudate Levels Amount exudate

5 Record of Checks (complete every shift) Night Late Early Record of Canister Changes and Exudate Levels Amount exudate

6 Record of Checks (complete every shift) Night Late Early Record of Canister Changes and Exudate Levels Amount exudate

7 Patient ID Label Patient / client name:... Address:... Adults and Community Division... of birth:... Topical Negative Pressure (TNP) Care Plan To provide an optimum environment to facilitate healing, reduce pain, reduce the risk of infection, reduce the wound exudate and reduce oedema to the wound edge. Specific Goals Needs / Preferences A. Identify where the ulcer/wound is positioned, size and document. B. Identify the cause of the ulcer/wound (i.e. pressure / venous hypertension / surgical). C. Identify other symptoms: 1. Oedema 2. Pain 3. Skin problems i.e. eczema, inflammation 4. Level of exudate 5. Describe wound bed i.e. slough, necrosis, granulation D. Ensure the patient understands the cause of the ulcer / wound and encourage them to ask questions and be involved in treatment decisions. E. Explain the use of TNP therapy and its role in wound healing. Give the appropriate information sheets and ensure information is understood. F. Obtain informed consent from the patient prior to commencing TNP therapy. G. Photograph wound ensuring consent is given for this. H. Apply the TNP therapy according to the treatment chart and in consultation with the Tissue Viability/Lymphoedema Team as per guidelines. I. Ensure all staff understand how to use the TNP therapy, change the canister and can recognize any problems with the dressing seal and what to do if a leak occurs. J. Ensure patient has a full wound assessment every days or more frequently if there is a change in the wound. Refer to treatment chart for dressing regime. K. If the wound shows no signs of healing following application of the TNP therapy for 6 weeks or if the ulcer heals, the patient should be referred back to the Tissue Viability / Lymphoedema Team for review of the wound or ongoing referral for further investigations, to determine the underlying cause. When documenting, use the letter that matches the care given.

8 Reference: Department of Health (2001) Essence of Care, DOH, London Start date Signed Print name Position Evaluation date Evaluation date Evaluation date Evaluation date Signature Signature Signature Signature Evaluation date Evaluation date Evaluation date Evaluation date Signature Signature Signature Signature Evaluation date Evaluation date Evaluation date Evaluation date Signature Signature Signature Signature If care plan is no longer required: care plan discontinued... Signature...

9 Additional information

10 Additional information

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12 Designed and printed by Clinical Illustration, South Birmingham Community Health Tel: Ref: /09