Wound Assessment Chart
2
PATIENTS NAME: DOB: HOSPITAL/NHS NUMBER: TYPE OF WOUND & LOCATION (if pressure damage include stage & date reported on Datix): WOUND LOCATION PLEASE TICK WOUND TYPE (complete separate sheet for each wound) Pressure Ulcer Moisture Lesion Diabetic Foot Ulcer Traumatic Wound Burn/Scald Fungating Wound Sinus/Fistula Surgical Wound (dehiscence) Skin Tear / Laceration Leg Ulcer Other: WOUND DURATION Acute (<6 wks) Chronic (>6 wks) ALLERGIES (include dressing products): PATIENT FACTORS WHICH MAY DELAY WOUND HEALING (eg:Diabetes, Infection, Nutritional status, Medication) Does patient have Mental Capacity ? Has patient consented to treatment ? Or is care in the patient’s best interest? YES / NO YES / NO YES / NO PAIN ASSESSMENT SEVERITY 0 1 2 3 4 5 6 7 8 9 10 FREQUENCY At Dressing Change On Movement Continuous Other PRESSURE RELIEVING EQUIPMENT IN USE? MATTRESS: YES/NO Date ordered? HEEL PROTECTION YES/NO Date ordered? CUSHION: YES/NO Date ordered? OTHER: YES/NO Date ordered? INITIAL ASSESSMENT: Wound bed condition (100%) WOUND SIZE (in CM) EUPAP CLASSIFICATION ( Pressure ulcer grade/stage) Epithelising Width 1 2 3 4 Healthy Granulation Length Slough (Yellow/brown) Depth ABPI (Leg Ulcer) Necrotic (black/brown) Undermining DATE LEFT RIGHT Over granulation Tracking Mixed Tissue CONDITION OF SURROUNDING SKIN Fungating / Malignant Healthy/intact Dry/cracked Discoloured Fragile Bone / Tendon / Ligament Macerated Eczematous Oedematous Excoriated Cellulitic FURTHER BASELINE ASSESSMENT Infected/critically colonised PHOTOGRAPH TAKEN YES/NO WOUND MAPPED YES/NO INFECTION SUSPECTED Wound swab? Date taken: Result: Antibiotic therapy? Antimicrobial ? INITIAL WOUND MANAGEMENT PLAN Wound Management Aims: Debride Deslough Protect Hydrate Reduce Bacterial load Reduce Odour Keep Dry Encourage granulation Debridement method Cleansing Solution Barrier preparation/adhesive remover Other Instructions: Primary Dressing Secondary Dressing Fixation method/ Bandaging Frequency of Dressing change Reassessment Frequency: Weekly Monthly Next Reassessment Date Referral Required? TVN Foot Health Plastics Vascular Dietician Other: Reason for Referral: Assessed by: Name: Signature: Designation Date L R L R Lateral R L Medial L R Dorsal R Sole L WOUND ASSESSMENT CHART 09/14 WVG969
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Transcript of Wound Assessment Chart
PATIENTS NAME:DOB:HOSPITAL/NHS NUMBER:
TYPE OF WOUND & LOCATION (if pressure damage include
stage & date reported on Datix):
WOUND LOCATION
PLEASE TICK WOUND TYPE (complete separate sheet for each wound)Pressure Ulcer Moisture Lesion Diabetic Foot Ulcer Traumatic WoundBurn/Scald Fungating Wound Sinus/Fistula Surgical Wound (dehiscence)Skin Tear / Laceration Leg Ulcer Other:WOUND DURATION Acute (<6 wks) Chronic (>6 wks)ALLERGIES (include dressing products):
PATIENT FACTORS WHICH MAY DELAY WOUND HEALING (eg:Diabetes, Infection, Nutritional status, Medication)
Does patient have Mental Capacity ?
Has patient consented to treatment ?
Or is care in the patient’s best interest?
YES / NO YES / NO YES / NOPAIN ASSESSMENTSEVERITY 0 1 2 3 4 5 6 7 8 9 10FREQUENCY At Dressing Change On Movement Continuous Other
PRESSURE RELIEVING EQUIPMENT IN USE?MATTRESS: YES/NO Date ordered? HEEL PROTECTION YES/NO Date ordered?CUSHION: YES/NO Date ordered? OTHER: YES/NO Date ordered?
INITIAL ASSESSMENT:Wound bed condition (100%)
WOUND SIZE(in CM)
EUPAP CLASSIFICATION( Pressure ulcer grade/stage)
Epithelising Width 1 2 3 4Healthy Granulation Length
Slough (Yellow/brown) Depth ABPI (Leg Ulcer)Necrotic (black/brown) Undermining DATE LEFT RIGHTOver granulation Tracking
Mixed Tissue CONDITION OF SURROUNDING SKINFungating / Malignant Healthy/intact Dry/cracked Discoloured FragileBone / Tendon / Ligament Macerated Eczematous Oedematous Excoriated
Cellulitic FURTHER BASELINE ASSESSMENTInfected/critically colonised PHOTOGRAPH TAKEN YES/NO WOUND MAPPED YES/NO
INFECTION SUSPECTEDWound swab? Date taken: Result: Antibiotic therapy? Antimicrobial ?
INITIAL WOUND MANAGEMENT PLANWound Management Aims:
Debride Deslough Protect HydrateReduce Bacterial load Reduce Odour Keep Dry Encourage granulation
Debridement method Cleansing Solution
Barrier preparation/adhesive remover Other Instructions:
Primary Dressing Secondary Dressing
Fixation method/ Bandaging Frequency of Dressing change
Reassessment Frequency: Weekly Monthly Next Reassessment Date
Referral Required? TVN Foot Health Plastics Vascular Dietician Other:Reason for Referral:Assessed by: Name: Signature:
Designation Date
L RL R
L RR L
R
SoleDorsalLateral Medial
L
L RL R
L RR L
R
SoleDorsalLateral Medial
L
L RL R
L RR L
R
SoleDorsalLateral Medial
L
L RL R
L RR L
R
SoleDorsalLateral Medial
L
L RL R
L RR L
R
SoleDorsalLateral Medial
L
L RL R
L RR L
R
SoleDorsalLateral Medial
L
WOUND ASSESSMENT CHART
09/14 WVG969
PATIENTS NAME:DOB:HOSPITAL/NHS NUMBER:
TYPE OF WOUND & LOCATION (if pressure damage include stage
& date reported on Datix):
ALLERGIES (include dressing products):DATE:
Wound Bed Condition (100%)
Epithelialisation
Healthy Granulation
Slough
Black/brown necrotic tissue
Over granulating
Fungating/malignant
Mixed tissue (bone/tendon/ligament)
Amount & Colour of Exudate
None
Low
Moderate
Heavy
Size of Wound
Width (W)
Length (L)
Depth (D)
Undermining /Tracking
Odour YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
Wound Pain YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
Severity (patient’s score 1-10)
Infection
Nil
Suspected
Swab sent (date)
Infection confirmed
Condition of Surrounding Skin
Healthy/intact
Dry/cracked
Discoloured
Fragile
Macerated
Eczematous
Oedematous
Excoriated
Wound Mapped (attach grid) YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
Wound Photographed YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
Updated Management Plan YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
Cleansing Solution
Primary Dressing
Secondary Dressing
Fixation method/ Bandaging
Others: (Barrier prep/adhesive remover)
Frequency of Dressing change
Reassessment frequency: Weekly, Monthly
Referral Required? Please specify:
Assessment completed by (Print & Sign)
WOUND ASSESSMENT CHART
