Evaluation Note Template for Stage 2 Sacral Pressure Injury
Patient Information
- Patient Name: [Patient Name]
- Date of Evaluation: [Date]
- Medical Record Number: [MRN]
Chief Complaint
- Stage 2 sacral pressure injury
Wound Assessment
Wound Characteristics
- Location: Sacral region
- Stage: Stage 2 (partial-thickness loss of dermis presenting as a shallow open ulcer with a viable red-pink wound bed without slough) 1
- Size: [Length] x [Width] x [Depth] cm (measure with ruler)
- Wound bed appearance: [Describe color, granulation tissue, epithelialization]
- Exudate: [Amount (none, minimal, moderate, heavy), color, consistency, odor]
- Periwound skin: [Describe condition - intact, macerated, erythematous, edematous]
- Pain: [Rate on scale 0-10, characteristics]
Infection Assessment
- Signs of local infection: [Presence/absence of increased pain, erythema, edema, increased warmth, purulent drainage, malodor] 1
- Signs of biofilm formation: [Low-level chronic inflammation, delayed healing despite adequate care, increased exudate, poor granulation] 1
- Signs of systemic infection: [Fever, chills, elevated WBC, hypotension] 1
Risk Factors Assessment
- Mobility status: [Bedbound, chair-bound, ambulatory with assistance, independent]
- Nutritional status: [Well-nourished, at risk, malnourished]
- Incontinence: [Urinary, fecal, both, none]
- Comorbidities: [Diabetes, peripheral vascular disease, spinal cord injury, etc.]
- Current pressure redistribution surface: [Type of mattress, cushion]
Current Wound Management
- Cleansing agent: [Specify]
- Dressing type: [Current dressing]
- Frequency of dressing change: [Specify]
- Repositioning schedule: [Frequency]
Wound Bed Preparation (T.I.M.E)
- T (Tissue): [Describe need for debridement]
- I (Infection/Inflammation): [Describe signs of infection/inflammation]
- M (Moisture balance): [Describe exudate management needs]
- E (Edge advancement): [Describe wound edge condition] 1
Plan of Care
Wound Treatment
- Cleansing: Gentle cleansing with [specify solution] at each dressing change
- Debridement: [If needed, specify type]
- Primary dressing: Triangle-shaped hydrocolloid border dressing (shown to be more effective for sacral wounds than oval dressings) 2
- Secondary dressing: [If needed]
- Frequency: Change dressing every [X] days or when soiled/dislodged
Pressure Redistribution
- Support surface: [Recommend specific pressure-reducing mattress/overlay]
- Repositioning schedule: Turn and reposition every 2 hours
- Offloading device: [Specify if needed]
Infection Management
- Wound cultures: [Indicate if needed based on signs of infection]
- Antimicrobial dressings: [If indicated, specify type]
- Systemic antibiotics: [If indicated for systemic infection, specify] 3
Nutritional Support
- Dietary recommendations: 30-35 kcal/kg/day; 1.25-1.5 g protein/kg/day 1
- Supplements: [Micronutrients if needed - B6, B12, folate, zinc, vitamin C, vitamin D] 1
- Hydration: Ensure adequate daily fluid intake
Patient/Caregiver Education
- Repositioning techniques: [Specific instructions]
- Dressing change procedure: [Detailed instructions if self-care]
- Signs of complications: [What to watch for]
- Follow-up schedule: [Next appointment date]
Expected Outcomes
- Short-term goals: [Specific measurable goals for 1-2 weeks]
- Long-term goals: [Specific measurable goals for complete healing]
Follow-up Plan
- Reassess wound weekly
- Adjust treatment plan based on wound healing progress
- Consult wound specialist if no improvement within 2 weeks
Provider Information
- Provider Name: [Name]
- Credentials: [Credentials]
- Signature: ___________________
- Date: [Date]