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    Wound Assessment Chart

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    Anonymous H3DpmCZX
    This document contains a wound assessment chart for tracking a patient's wound over time. It collects information such as the patient's name and details, description of the wound type and location, allergies, factors that may delay healing, pain assessment, initial wound size and characteristics, wound bed condition, surrounding skin condition, exudate amount, infection information if present, treatment plan including dressings used, and reassessment frequency. The chart allows medical professionals to systematically document the key details of a wound and how it changes with treatment over multiple appointments.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Wound Assessment Chart

    Uploaded by

    Anonymous H3DpmCZX
    2K views2 pages
    This document contains a wound assessment chart for tracking a patient's wound over time. It collects information such as the patient's name and details, description of the wound type and location, allergies, factors that may delay healing, pain assessment, initial wound size and characteristics, wound bed condition, surrounding skin condition, exudate amount, infection information if present, treatment plan including dressings used, and reassessment frequency. The chart allows medical professionals to systematically document the key details of a wound and how it changes with treatment over multiple appointments.

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    This document contains a wound assessment chart for tracking a patient's wound over time. It collects information such as the patient's name and details, description of the wound type and location, allergies, factors that may delay healing, pain assessment, initial wound size and characteristics, wound bed condition, surrounding skin condition, exudate amount, infection information if present, treatment plan including dressings used, and reassessment frequency. The chart allows medical professionals to systematically document the key details of a wound and how it changes with treatment over multiple appointments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views2 pages

    Wound Assessment Chart

    Uploaded by

    Anonymous H3DpmCZX
    This document contains a wound assessment chart for tracking a patient's wound over time. It collects information such as the patient's name and details, description of the wound type and location, allergies, factors that may delay healing, pain assessment, initial wound size and characteristics, wound bed condition, surrounding skin condition, exudate amount, infection information if present, treatment plan including dressings used, and reassessment frequency. The chart allows medical professionals to systematically document the key details of a wound and how it changes with treatment over multiple appointments.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    WOUND ASSESSMENT CHART

    PATIENTS NAME:
    DOB:
    HOSPITAL/NHS NUMBER:

    TYPE OF WOUND & LOCATION (if pressure damage include


    stage & date reported on Datix):

    WOUND LOCATION

    LR

    LR

    LR L R L R
    L
    Lateral

    L RR L

    RR

    LR
    LR
    L
    RLLR L R R LR R L R RL

    LR
    LRRLL
    L L

    RR

    RL R R LR

    L L

    Medial
    Dorsal
    Sole DorsalDorsal
    Lateral Lateral
    LateralLateral
    Medial
    Lateral
    Medial
    Medial
    Dorsal
    Medial
    Medial
    Dorsal
    Sole
    DorsalSole Sole Sole
    Sole

    PLEASE TICK WOUND TYPE (complete separate sheet for each wound)
    Pressure Ulcer
    Moisture Lesion
    Burn/Scald
    Fungating Wound
    Skin Tear / Laceration
    Leg Ulcer
    WOUND DURATION
    Acute (<6 wks)
    ALLERGIES (include dressing products):

    Diabetic Foot Ulcer


    Sinus/Fistula
    Other:
    Chronic (>6 wks)

    PATIENT FACTORS WHICH MAY DELAY WOUND


    HEALING (eg:Diabetes, Infection, Nutritional status, Medication)

    Traumatic Wound
    Surgical Wound (dehiscence)

    Does patient
    have Mental
    Capacity ?

    Has patient
    consented to
    treatment ?

    YES / NO

    YES / NO

    Or is care in the
    patients best
    interest?
    YES / NO

    PAIN ASSESSMENT
    SEVERITY
    FREQUENCY

    0
    1
    At Dressing Change

    4
    On Movement

    6
    Continuous

    8
    Other

    10

    PRESSURE RELIEVING EQUIPMENT IN USE?


    MATTRESS: YES/NO Date ordered?
    CUSHION:
    YES/NO Date ordered?
    INITIAL ASSESSMENT:
    Wound bed condition (100%)

    HEEL PROTECTION
    OTHER:
    WOUND SIZE
    (in CM)

    YES/NO Date ordered?


    YES/NO Date ordered?
    EUPAP CLASSIFICATION
    ( Pressure ulcer grade/stage)

    Epithelising

    Width

    Healthy Granulation

    Length

    Slough (Yellow/brown)

    Depth

    Necrotic (black/brown)

    Undermining

    Over granulation

    Tracking

    ABPI (Leg Ulcer)


    DATE

    LEFT

    RIGHT

    CONDITION OF SURROUNDING SKIN

    Mixed Tissue
    Fungating / Malignant
    Bone / Tendon / Ligament

    Healthy/intact
    Macerated

    Dry/cracked
    Eczematous

    Discoloured
    Oedematous

    Fragile
    Excoriated

    FURTHER BASELINE ASSESSMENT

    Cellulitic

    PHOTOGRAPH TAKEN

    Infected/critically colonised

    YES/NO

    WOUND MAPPED

    YES/NO

    INFECTION SUSPECTED
    Wound swab?

    Date taken:

    Result:

    Antibiotic therapy?

    Antimicrobial ?

    INITIAL WOUND MANAGEMENT PLAN


    Wound
    Management Aims:
    Debridement method

    Debride
    Reduce Bacterial load

    Deslough
    Reduce Odour

    Protect
    Keep Dry
    Cleansing Solution

    Hydrate
    Encourage granulation

    Barrier preparation/adhesive remover

    Other Instructions:

    Primary Dressing

    Secondary Dressing

    Fixation method/ Bandaging

    Frequency of Dressing change

    Reassessment Frequency:

    Weekly

    Referral Required? TVN


    Reason for Referral:

    Foot Health

    Assessed by:

    Monthly

    Plastics

    Next Reassessment Date

    Vascular

    Dietician

    Name:

    Signature:

    Designation

    Date

    Other:

    09/14 WVG969

    WOUND ASSESSMENT CHART


    TYPE OF WOUND & LOCATION (if pressure damage include stage

    PATIENTS NAME:
    DOB:
    HOSPITAL/NHS NUMBER:

    & 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

    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

    Severity (patients 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

    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)

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