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Wound Assessment form Date: Patient Name: Patient ID: Patient Wound description Age:years Wound type: Weight:kgs Duration of wound: Gender: MaleFemale Previous treatments: Nutrition status: Well nourished Malnourished Mobility status: Good mobility Bad Mobility Smoking: YesNo If yes, how many/day: Size: length mm width mm depth mm Wound location (please circle wound): Alcohol:units/week Co-morbidities: Pain level: Medications: 0 ABPI (if done): 1 2 3 No pain Date: Tissuetype type • •Tissue • Exudate • Exudate Infection • •Infection Necrotic Necrotic Sloughy Sloughy Wound bed Assessment • Tissue type • Exudate • Infection nd edge edge Periwound skin Wound edge Assessment Periwound skin Wound bed Periwound skin Assessment Wound edge Periwound skin 7 8 9 % % % % LevelNecrotic Level Sloughy Dry% Dry % Granulating Granulating Epithelialising Epithelialising Low Low Granulating Epithelialising % % % % Thin/watery Thin/watery Low Medium Purulent Purulent Medium % Medium % High High Cloudy Cloudy Clear Clear Thick Thick Pink/red Pink/red Level Dry Type Thin/watery Cloudy Thick Purulent Clear Pink/red Infection Local Local Local Increased pain Increased pain Erythema Increased pain Erythema Spreading/systemic Increased erythema Oedema Erythema Local warmth Oedema Increased exudate Oedema Delayed healing Local warmth Friable granulation tissue Local warmth Increased Malodour exudate Pocketing Increased exudate Delayed healing Delayed healing tissue Friable granulation Friable granulation tissue Malodour Malodour Pocketing Pocketing High Pyrexia Abscess/pus Wound breakdown Cellulitis General malaise Raised WBC count Lymphangitis 10 Worst pain Exudate Type Type WOUND Periwound skin Assessment Periwound skin Assessment 6 Wound bed Assessment Tissue type Wound bed Wound bed 5 Moderate pain Wound bedWound assessment Wound bedAssessment Assessment bed WOUND WOUND 4 Spreading/systemic Spreading/systemic Increased erythema Increased erythema Pyrexia Pyrexia Abscess/pus Abscess/pus Wound breakdown Wound breakdown Cellulitis Cellulitismalaise General General malaise Raised WBC count Raised WBC count Lymphangitis Lymphangitis Wound edge assessment Wound edge Wound Assessment Wound bed Assessment Woundedge edgeWound Assessment Wound Assessment Maceration Wound bed AssessmentWound bed Assessment Wound edge Wound Assessment Maceration Maceration Dehydration Maceration Wound bed Dehydration Undermining Wound bed WOUND Wound Assessment skin Assessment Wound bed • Maceration • Dehydration • Undermining • Thickened/rolled edges WOUND Wound edge Periwound skin Periwound WOUND Rolled edges Wound Assessment Periwound skin Assessment Wound edge Extent: ____ cm Rolled edges Wound edge Assessment • Maceration • Dehydration • Undermining • Thickened/rolled edges Mark position Dehydration Undermining Undermining Rolled edges Wound edge Assessment Dehydration Undermining Periwound skin Rolled edges Wound Assessment Periwound skin Assessment Periwound skin assessment Wound edge Periwound skin Periwound skin Wound Assessment Periwound skinWound Assessment Periwound skin Assessment Wound WoundAssessment bed Assessment Maceration Wound WoundAssessment bed Assessment CM Maceration Wound bed Wound edge WOUND Periwound skin Periwound skin Assessment Hyperkeratosis Callus Eczerma Periwound skin Management goals • Manage exudate • Protect skin • Rehydrate skin • Remove non-viable tissue Treatment choice Dressing type/name: Reason for choosing dressing: Follow up plan Date of next visit: Main objective at next visit: Coloplast A/S, Holtedam 1, 3050 Humlebaek, Denmark www.coloplast.com The Coloplast logo is a registered trademark of Coloplast A/S. © 2017.04. All rights reserved Coloplast A/S cm CM CM Management Goals Write all management goals Periwound skin Assessment • Manage exudate • Rehydrate wound edge • Remove non-viable tissue • Protect granulation/epithelial tissue CM Callus WOUND Treatment: cm Static Improving • Remove non-viable tissue • Manage exudate • Manage bacterial burden • Rehydrate wound bed • Protect granulation/epithelial tissue Management goals CM cm CM Hyperkeratosis Management goals Wound edge CM Eczema Eczerma Wound Wound edge Assessment CM cm Dry skin • Maceration Status • Excoriation Wound edge Periwound skin • Dry skinDeteriorating Is the wound: N/A- First visit • Hyperkeratosis • Callus Management goals • Eczema Wound bed Assessment Wound bed CM Dry skin Hyperkeratosis Callus CM cm Excoriation • Maceration • Excoriation • Dry skin • Hyperkeratosis • Callus • Eczema Periwound skin Assessment Tick all appropriate management goals CM Excoriation Dry skin WOUND Wound edge Assessment cm Maceration Excoriation Wound bed CM
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