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Wound assessment is a component of wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.
A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer. [6] The Braden Scale assessment score scale: Very High Risk: Total Score 9 or less. High Risk: Total Score 10-12. Moderate Risk: Total Score 13-14.
Nursing assessment. Nursing assessment is the gathering of information about a patient 's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
Periwound. The periwound (also peri-wound) is tissue surrounding a wound. Periwound area is traditionally limited to 4 cm outside the wound's edge but can extend beyond this limit if outward damage to the skin is present. Periwound assessment is an important step of wound assessment before wound treatment is prescribed. [1]
Waterlow score. The Waterlow score (or Waterlow scale) gives an estimated risk for the development of a pressure sore in a given patient. The tool was developed in 1985 by clinical nurse teacher Judy Waterlow. It is available both on a two-sided score card and on an app.
Controlling the heat and moisture levels of the skin surface, known as skin microclimate management, may also play a role in the prevention and control of pressure ulcers. [74] Skin care is also important because damaged skin does not tolerate pressure. However, skin that is damaged by exposure to urine or stool is not considered a pressure ulcer.
Total body surface area. Total body surface area (TBSA) is an assessment of injury to or disease of the skin, such as burns or psoriasis. In adults, the Wallace rule of nines can be used to determine the total percentage of area burned for each major section of the body. [1]
The Pediatric Assessment Triangle or PAT is a tool used in emergency medicine to form a general impression of a pediatric patient. [1] In emergency medicine, a general impression is formed the first time the medical professional views the patient, usually within seconds. [2] The PAT is a method of quickly determining the acuity of the child ...
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