| RISK FACTORS |
| ( ) ICU hospitalization ( ) Immobility ( ) Decreased sensory perception ( ) Hyperthermia ( ) Edema ( ) Malnutrition ( ) Obesity ( ) Hypoalbuminemia ( ) Anemia ( ) Moisture exposure ( ) Diarrhea ( ) Urge urinary incontinence ( ) Excessive sweating ( ) Exposure to wound exudate |
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PSYCHOBIOLOGICAL NEEDS
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OXIGENATION
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Respiratory rate: ______ rpm.
( ) Apnea ( ) Bradypnea ( ) Tachypnea ( ) Dyspnea ( ) Orthopnea ( ) Eupnea ( ) Cyanosis
Thoracic expandability: ( ) Unilateral ( ) Bilateral.
Ventilatory assistance: ( ) CPAP ( ) HOOD ( ) MVA ( ) Nasal oxygen catheter |
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HYDRATION AND ELECTROLYTIC REGULATION
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| ( ) Edema ( ) Decreased skin elasticity ( ) Dry skin |
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NUTRITION
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| Route of diet administration: ( ) oral ( ) NET ( ) NGT ( ) PEG ( ) zero diet ( ) Hypoglycemia ( ) Hyperglycemia ( ) Dysphagia ( ) Abdominal pain ( ) Food intolerance ( ) Nausea ( ) Vomiting ( ) Diet restriction |
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ELIMINATION
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Stool elimination frequency: ______ ( ) Constipation ( ) Diarrhea ( ) Dysuria ( ) Enterorrhagia ( ) melena
Frequency of urine elimination: _______ ( ) Anuria ( ) Choluria ( ) Nocturia ( ) Oliguria ( ) Polaciúria ( ) Urinary retention ( ) Poliuria ( ) Spontaneous urination ( ) Hematuria ( ) Urinary incontinence |
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SLEEP AND REST
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| ( ) satisfactory sleep ( ) insomnia ( ) impaired sleep ( ) sleepiness |
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LOCOMOTION, BODY MECHANICS AND MOTILITY
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| ( ) Change in level of consciousness ( ) Muscle atrophy ( ) No ambulation ( ) Use of crutches ( ) Use of wheelchair ( ) Ambulation ( ) Ambulation with help ( ) Ambulation with difficulty ( ) Fatigue ( ) Preserved motor strength ( ) Body movement: reduced, increased, normal, assisted ( ) Paralysis ( ) Paresis ( ) Paresthesia ( ) Movement restriction |
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SKIN-MUCOUS INTEGRITY
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Anatomical location of the injury: ______________________
Injury stage: ( ) I ( ) II ( ) III ( ) IV ( ) unstageable ( ) medical device injury ( ) deep tissue injury ( ) mucous membrane injury
Injury area: length:________ width:________ Depth: ( ) flat ( ) tunnels ( ) fistulas
Wound edges: ( ) adherent ( ) epithelialized ( ) well defined ( ) detached ( ) fibrotic/rigid to the touch ( ) hyperkeratosis/ callus tissue ( ) macerated
Exudate amount: ( ) little ( ) moderate ( ) heavy
Exudate odor: ( ) absent ( ) characteristic ( ) fetid
Exudate aspect: ( ) absent ( ) serous ( ) serosanguineous ( ) bloody ( ) purulent
( ) seropurulent
Type of wound bed tissue: ( ) granulated ( ) slough ( ) eschar ( ) epithelialization
Signs of infection: ( ) edema ( ) increased temperature ( ) hyperemia ( ) increased necrotic tissue ( ) absent
Periwound skin: ( ) intact ( ) signs of inflammation ( ) dermatitis ( ) macerated
Duration of injury: ____________ Origin of injury: _____________________________ |
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THERMAL REGULATION
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| Axillary temperature: ___ C ( ) Chills ( ) Hyperthermia ( ) Hypothermia ( ) Cold skin ( ) Hot skin ( ) Febrile state |
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NEUROLOGICAL REGULATION
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( ) Alteration in reflexes ( ) Mental confusion ( ) Convulsive crisis ( ) Delirium ( ) Disorientation
( ) Normal motor strength Level of consciousness: _________ ( ) Paresis ( ) Paresthesia |
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PAIN PERCEPTION
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Behaviour
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Scale
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0
|
1
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2
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Face
Legs
Activity
Cry
Consolability |
No particular expression or smile
Normal position or relaxed
Lying quietly, normal position, moves easily
No cry (awake or asleep)
Content, relaxed |
Occasional grimace or frown
Uneasy, restless, tense
Squirming, shifting, back and forth, tense
Moans or whimpers; occasional complaint
Reassured by touching, hugging or being talked to, distractible |
Frenquent to constant quivering chin, clenched jow
Kicking or legs drawn up
Arched, rigid or jerking
Crying steadily, screams, sobs, frequent complaints
Difficult to console or comfort |
FLACC SCALE SCORE:
The child or adolescent must be uncovered, sleeping or awake. Observe the patient for 1 to 5 minutes to identify characteristics related to five categories.
0 = no pain; 1 to 3 = mild pain; 4 to 6 = moderate pain; and 7 to 10 = severe pain. Record in the electronic medical record. If pain is identified, discuss with the team what action to take. |
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BASIC HUMAN NEEDS OF VASCULAR REGULATION
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| ( ) Normocardia ( ) Bradycardia ( ) Tachycardia ( ) Heart rate: ( ) Regular ( ) Irregular ( ) Arrhythmia ( ) Presence of murmurs, cyanosis, ecchymosis, bruising, hematuria, bleeding. Specify: ___________ ( ) Pulse type: ( ) Normal ( ) Strong/full ( ) Weak/fine ( ) Irregular |
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SIGNS OF INFECTION
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( ) Slough granulation tissue ( ) Bad smell ( ) Increased pain in injury
( ) Increased wound drainage and changes in wound characteristics (recurrence of blood on drainage, purulent feature);
( ) Greater amount of necrotic tissue in wound bed;
( ) Appearance of pockets or necrosis in wound bed;
( ) No signs of healing after two weeks of appropriate treatment. |
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HUMAN THERAPEUTIC NEEDS
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Injury cleaning: ( ) saline solution ( ) distilled water ( ) PHMB
Dressing used: ( ) hydrogel ( ) polyurethane foam ( ) non sterile film ( ) alginate ( ) alginate with silver ( ) hydrocolloid others:_____________________________
Recommendations on dressing change: ____________________________________ |
Management tools in nursing care for children with pressure injury
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