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