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KKM Wound Borang Kemajuan Luka

This document contains guidelines for wound care services in primary health care facilities. It includes forms for wound assessment, wound progress evaluation, and wound care plans. The forms collect patient information, wound characteristics, examination results, diagnosis, treatment plan including dressing types and frequency of follow-up, education provided, and referrals made.

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rebecca
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1K views4 pages

KKM Wound Borang Kemajuan Luka

This document contains guidelines for wound care services in primary health care facilities. It includes forms for wound assessment, wound progress evaluation, and wound care plans. The forms collect patient information, wound characteristics, examination results, diagnosis, treatment plan including dressing types and frequency of follow-up, education provided, and referrals made.

Uploaded by

rebecca
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GARIS PANDUAN PERKHIDMATAN PENJAGAAN LUKA DI FASILITI KESIHATAN PRIMER

Lampiran 3

BORANG PENILAIAN LUKA


KLINIK KESIHATAN :

NOMBOR PENDAFTARAN : TARIKH :

MAKLUMAT PERIBADI

NAMA :

NO. KP/ PASSPORT :

UMUR :

JANTINA :

BANGSA :

ALAMAT :

PEKERJAAN :

NO. TELEFON :

MASALAH SEMASA (CHIEF COMPLAINT)

SEJARAH PESAKIT/ FAKTO RISIKO

DIABETES AUTOIMMUNE DISEASE

HYPERTENSION CANCER/ MALIGNANCY

PERIPHERAL VASCULAR DIASEASE/ VENOUS INSUFFICIENCY SMOKER

DIABETES BMI OTHERS eg: CKD, IHD, CVA, COPD

SEJARAH UBAT / CURRENT DRESSING

SEJARAH SOSIAL

m/s 1

22
GARIS PANDUAN PERKHIDMATAN PENJAGAAN LUKA DI FASILITI KESIHATAN PRIMER

TANDA VITAL

BP : HR : SPO2 : TEMP : RBS : PAIN SCORE :

LOKASI LUKA

SILA LAKARKAN
LOKASI LUKA

BIL. LUKA 1 2 3 4 5 6

PANJANG (CM)

LEBAR (CM)

DALAM (CM)

PENILAIAN LUKA

PENYIASATAN MAKMAL/ RADIOLOGI

UJIAN JENIS / TARIKH / KEPUTUSAN

BLOOD

XRAY

CULTURE

DIAGNOSIS

JENIS LUKA

CANCER WOUND SURGICAL WOUND

PRESSURE INJURY TRAUMATIC WOUNDS

DIABETIC ULCER BURNS

VENOUS ULCER OTHERS

m/s 2

23
GARIS PANDUAN PERKHIDMATAN PENJAGAAN LUKA DI FASILITI KESIHATAN PRIMER

PELAN PERAWATAN LUKA


1. Cleansing Solution
Superoxidise Solution Water For Irrigation
PHMB (polyhexamethylene biguanide) Diluted Povidone - Iodine Solution
Octenidine Dihydrochloride Others :

2. Primary Dressing
Hydrogel : Collagen :
Polymeric Membrane Dressing :
Anti-microbial gel :
Foam :
Alginate gel : Others :

3. Secondary dressing
Tulle dressing : Polymeric membrane dressing :
Film Dressing : Foam :
Alginate : Gauze / gamgee :
Others :

4. Skin Protection / Barrier


Aqueous cream : Barrier Spray / Cream :
Zinc Oxide : Others :
Collagen lotion :

5. Compression Bandage
Stockinette Type : _______________________

6. Patient’s Education
Personal Hygiene Wound site Advise
Turning and Positioning Nutritional
Sign of wound infection Others :

7. Rujukan
Pegawai Dietetik Pegawai Farmasi
Pegawai Sains Pemakanan Hospital
Pegawai Kerja Sosial Perubatan

8. Temujanji :

Tandatangan : Nama / cop :

m/s 3

24
GARIS PANDUAN PERKHIDMATAN PENJAGAAN LUKA DI FASILITI KESIHATAN PRIMER

Lampiran 4
KKM/BPKK/WC 301-2018

BORANG KEMAJUAN LUKA

NAME : I/C :

WOUND :

DATE OF DRESSING
SIZE OF WOUND
LENGTH (CM)
WIDTH (CM)
DEPTH (CM)
TISSUE VIABILITY
<25 >25 <25 >25 <25 >25 <25 >25 <25 >25
% OF SLOUGH / NECROTIC
% RED (GRANULATION TISSUE)
% PINK (EPITHELIAL TISSUE)
INFECTION
PRESENT (systemic / local)
NO
MOISTURE (EXUDATE)
DRY
MINIMAL
WET MODERATE
HEAVY
WOUND EDGES (Healthy, Maceration, Dehydration, Rolled Edges, Undermining)

PERIWOUND SKIN (Healthy, Maceration, Excoriation, Dry, Hyperkerotosis, Callus, Eczema)

DRESSING SOLUTION

DRESSING MATERIAL

RANDOM BLOOD GLUCOSE


PAIN SCORE
DEBRIDEMENT METHOD
CULTURE TAKEN (DATE)
TYPES OF ANTIBIOTIC
TCA / FOLLOW UP
DRESSING DONE BY
DOCUMENTED BY
COMMENTS

m/s 1

25

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