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Progress Note: Simple surgical wounds - removal of staples and sutures

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Skin assessment - information for clinicians (Clinical Excellence Commission)

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Skin assessment - information for clinicians (Clinical Excellence Commission)

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Reference:

Clinical Excellence Commission. (2021). Skin assessment - Information for clinicians. https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/664226/Skin-assessment-information-for-clinicians.PDF

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The name of the CAP203 psychosocial assessment: Psychosocial assessment

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The name of the CAP203 psychosocial assessment: Psychosocial assessment

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As a medical/surgical nurse, we evaluate our patient's psychosocial assessment.

The social aspect considers family support.

The psychology aspect evaluated the patient's emotional state.

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Wound Chart: Complex wounds

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Bates-Jensen Wound Assessment Tool - for complex wounds

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Bates-Jensen Wound Assessment Tool - for complex wounds

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Wound chart: use for chronic or complex wounds

Simple or surgical wounds: use the progress notes

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Venous Thromboembolism (VTE) Risk Assessment Tool

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Venous Thromboembolism (VTE) Risk Assessment Tool

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Waterlow Pressure Ulcer Score - NSW and VIC

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Waterlow Pressure Ulcer Score - NSW and VIC

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Image Reference: Scott, K., & Longstaffe, S. (2020). Judy Waterlow. Life in the Fast Lane. https://litfl.com/judy-waterlow/

The Waterlow Score, developed by Judy Waterlow in 1985 and revised by Queensland Health in 2005, assesses risk across six categories (Scott & Longstaffe, 2020, "Waterlow score" section, para. 2). It integrates the Malnutrition Screening Tool (MST) for nutritional evaluation and has a "Special risks" section. Scores above 10 indicate risk, scores above 15 indicate high risk, and scores above 20 indicate very high risk. The back contains prevention strategies and wound guidelines and definitions.

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Pressure Injury Risk Assessment Form (MR95) - South Australia 

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Pressure Injury Risk Assessment Form (MR95) - South Australia 

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Adult Pressure Injury Risk Assessment: Queensland

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Adult Pressure Injury Risk Assessment: Queensland

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NSW Health Alcohol Withdrawal Scale (for use in inpatient settings)

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Mini Mental State Examination (MMSE) - NSW

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Mini Mental State Examination (MMSE) - NSW

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Adult Admission and Discharge Assessment (8) (1)

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NSW Health Adult Admission and Discharge Assessment (8)

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Australian Commission on Safety and Quality in Health Care

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Venous Thromboembolism Prevention Clinical Care Standard: Implementation Guide | Australian Commission on Safety and Quality in Health Care

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This document supports the implementation of the Venous Thromboembolism Prevention Clinical Care Standard. Each section of the guide includes tips for implementation, case studies and examples of venous thromboembolism (VTE) prevention strategies, reflective questions and useful resources.

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Focused Body Assessment, based on what you learned in HAS108. 

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Focused Body Assessment, based on what you learned in HAS108. 

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Only include physical assessments you have learned in the Torrens Bachelor of Nursing course.

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Do not use the Braden Scale for CAP203: This risk assessment tool is used for medically and cognitively impaired older adults 

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Do not use the Braden Scale for CAP203: This risk assessment tool is used for medically and cognitively impaired older adults 

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We will not use this assessment tool in CAP203!

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NSW Health PCA (Patient Controlled Analgesia) (Adult)

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NSW Health PCA (Patient Controlled Analgesia) (Adult)

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Written by NSW Agency for Clinical Innovation (ACI)

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We will not use Mental Health assessments in CAP203. 

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We will not use Mental Health assessments in CAP203. 

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Instead, you will use psychosocial assessment - a basic nursing assessment. 

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Instead, you will use psychosocial assessment - a basic nursing assessment. 

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Crisp et al. (2021): Chapter 7 (p. 121) - Psychosocial Assessment

Reference: Crisp, J., Douglas, C., Rebeiro, G., & Waters, D. (2020). Potter and Perry’s Fundamentals of Nursing (6th ed.). Elsevier Australia. https://clinicalkeymeded.elsevier.com/books/9780729587983