Grand Rounds: History Of Present Illness, Segment #2

History of Present Illness

Physical Examination:
1. Partial thickness necrosis and infection of R Achilles tendon
2. No palpable DP, PT pulses B/L
3. No signs of fascial or osseous tracking of infection
4. Passive ROM of ankle was painful during examination. Unable to bear weight on R foot

Progressive Plan of Care

These are the first four of the Essentials as they appear in the flow sheet in CPG W01.01

1. Adequate perfusion and/or oxygenation
2. Removal of all non-viable tissue present
3. Infection and/or inflammation controlled
4. Edema controlled, venous reflux treated

These are the last five of the Essentials as they appear in the flow sheet in CPG W01.01
5. Wound microenvironment optimized to support healing
6. Tissue growth optimized
7. Offloading and/or pressure relief appropriate
8. Pain controlled
9. Host factors optimized 

When the NHC Wound Healing Clinical Assessment Pathway is reviewed with reference to the Nine Essentials, the concordance is obvious.

W05.01 Essential 1: Essential Step 1A/B Perfusion and Oxygenation.

The design of each Clinical Practice Guideline addressing the Nine Essentials includes the appropriate section of the decision tree or flow sheet, Critical Principles, and a detailed section describing appropriate steps in Assessment and appropriate steps in Treatment, decision trees or flow sheets, and other important supplemental information and references are then provided.

In the HealSource™ document, for the sake of brevity and greater utility of this condensed pocket version, only the decision tree or flow sheet segment, Critical Principles, and additional decision tree are included as in this example.

Note the Critical Principles with the guiding principle being that (1) all patients with a lower extremity wound need additional arterial vascular assessment beyond a vascular history, pulse examination, and ABI because of the importance of malperfusion and hypoxia in this subset of the population at large, and (2) all patients suspected of having a VLU should receive a properly performed venous duplex ultrasound.