wound Assessment

Card Set Information

Author:
calacedra13
ID:
92799
Filename:
wound Assessment
Updated:
2011-07-02 20:01:26
Tags:
history
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Description:
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  1. HISTORY
    1. Chief Complaint
    • Pt's perception of problem
    • His goals
  2. HISTORY
    2. Present Illness
    • Onset; date, speed; rash, trauma, callus
    • Past & present Tx and cleaning method, response
    • Sx associated with Ulcer
    • Pain; Location, Quality, Severity, Timing, Modifying factors
  3. 3. HISTORY
    Past Medical
    • Circulation; PAD, PVD & risk factors. VI & DVT
    • hematologic, microthrombotic disorders, Vasospastic
    • Liver disease/ hep C
    • Inflammatory; Autoimmune (RA, Scleroderma, SLE) inflammatory bowel disease
    • Metabolic; DM, renal failure/insuff. (nutritional, calciphlaxis)
    • Infection hepatitis, TB, HIV
    • Neuro neuropathy, paralysis, paresis
    • Musculoskeletal
    • Surgeries reconstructive, revascularization (stents, bypass, angioplasty) vein stripping, amputation
    • accidents lower extremities; gait, CVI, hardware
  4. HISTORY
    4. Current Health
    • Meds; steriods, chemo
    • Allergies
    • Habits; smoking, alcohol, illecit drugs
    • Diet; appetite, intake, special needs
  5. HISTORY
    5. Family History
    • genetic related diseases
    • DM, HD, HTN, CVA, TB, Ca, arthritis, kidney disease, lower extremity wounds
  6. HISTORY
    6. Social history
    • living arrangement; able to help with wound care
    • Leisure activities enjoyed and how wound affects this

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