Record the date and time of each entry.
Record the type of walker used, such as a standard, stair, or reciprocal walker.
Note whether any attachments are used, including platform attachments or wheels.
Describe the degree of guarding that the patient requires.
Document the distance walked and the patient’s tolerance.
Document all education related to the use of the walker.
|
Document the date and time with each entry. Many facilities also have a special form or flow sheet on which to document wounds. (See Wound and skin assessment tool, pages 435 and 436.) Include the following for wound assessment:
wound size, including length, width, and depth in centimeters
wound appearance: color, edema, irregularities, surrounding tissue
wound shape
wound site, drawn on a body plan to document exact location
wound stage
characteristics of drainage, if any, including amount, color, and presence of odor
characteristics of the wound bed, including description of tissue type, such as granulation tissue, slough, or epithelial tissue
character of the surrounding tissue
presence or absence of eschar
presence or absence of pain
presence or absence of undermining or tunneling (in centimeters).
|
ACCUCHART
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
