Policy Number LCH-121 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A – Information about this Document Policy Name Wound Assessment Guideline Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care’s Executive Director / Lead for this document, I confirm that this document: complies with the latest statutory / regulatory requirements, complies with the latest national guidance, has been updated to reflect the requirements of clinicians and officers, and has been updated to reflect any local contractual requirements Signature: Date: Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only) Terminology used in this Document New terminology when reading this Document Part C – Additional Information Added (to be used with ‘Major Changes’ only) Section / Paragraph No Outline of the information that has been added to this document – especially where it may change what staff need to do Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only) Please explain why this new document needs to be adopted or why this document is no longer required Part E – Oversight Arrangements (to be used with ‘New Policy’ only) Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process – Form 1
Title Wound Assessment Clinical Guideline Guideline reference number 121 Aim and purpose of clinical document To provide evidence-based guidance on the wound assessment process Author Skin Care Service Type New document Reviewed document √ Review Date February 2018 – 1 month extension agreed at Clinical Standards Group meeting 24.01.18 Person/group accountable for review Skin Care Service Type of Evidence base used C: Evidence which includes published and/or unpublished studies and expert opinion (limited scientific evidence) Issue date January 2016 Authorised by Clinical Standards Group January 2016 – amendment noted at meeting on 25th July 17 Impact Assessment Undertaken Yes √ date when 03.02.2015 No Evidence collated √ n
12 Is there documented evidence that the condition of the surrounding skin has been recorded? None CRITERION EXCEPTION COMPLIANCE ACHIEVED YES NO N/A 13 Is there documented evidence that the % tissue type in the wound bed has been assessed? None 14 Is there documented evidence that the patient and the wound have been assessed for clinical signs of infection? None If there is documented evidence that clinical signs of infection are present please also complete infected wound audit tool. Communication 15 Is there documented evidence that the risks, benefits and alternative treatments have been discussed with the patient? None 16 Is there documented evidence that consent to treatment has been obtained? None Care Planning and Evaluation 17 Is there documented evidence that the wound management plan (e.g. wound dressing selection) has been recorded None 18 Was the wound dressing used in line with LCH formulary? * Clinical rationale provided for non formulary prescribing* *Identify which non formulary products where used.(if applicable) 19 Did the wound dressing selection appear appropriate for the clinical characteristics of the wound? if NO provide details below* None * 20 Is there documented evidence that a wound care plan has been recorded with review date identified? Where only one visit was required 21 Did the frequency of dressing change appear sufficient for clinical need? Where only one visit was required 22 Is there documented evidence that the expected result of wound care plan (eg wound debridement / granulation etc) has been identified? Where only one visit was required 23 Is there documented evidence that the wound care plan has been reviewed at identified review dates? Where only one visit was required
Box I : Systemic Inflammatory Response Syndrome (SI RS): SIRS is present if there are at least 2 of: Temperature >38.3 or <36.0°C New confusion/drowsiness Pulse > 90/min IIBC 2 01 4.G JIL RR >10/min Blood glucose >7.7 mmoi!L (not if diabetic) Box 2 : Defining the severity of sepsis Severity Definition Group mortality sepsis SIRS + presumed or confirmed infection 10% Sepsis + oneor more organ dysfunction criteria (other than shock) JS% Septic shock Sepsis + shock"' 50% *Shock criteria: lactate >4mmolj1 at any time point Hypotension persisting after JOml/kg intravenous fluid,defined as Systolic Blood Pressure <90mmHg, Hean Blood Pressure <65mmHg,or a fall of >40mmHg from the patient's usual Systolic Blood Pressure UKST PRIMARY CARE TOOLKIT 2014 j 5