Wound Assessment form

Date: Patient Name:

15/02/2019 Tn. J

Patient ID: Assessor Name: AA

Patient
Age: 45 years
Weight: 75 kgs
Gender: √ Male Female

Nutrition status: √ Well nourished Malnourished

Mobility status: Good Mobility √ Bad Mobility
Smoking: √ Yes No
If yes, how many/day: 5
batang/hari

Alcohol: Yes √ No
If yes, units/week:

Co-morbidities: Venous disease Arterial disease

Diabetes Anaemia

Other: spinal
cord injury
Medications:
Allergies:
tidak ada
ABPI (done): Yes √ No
If yes,measurement:
Date:
Wound description
Wound type(s): ulcers sore
Duration of wound(s): 3 bulan
Previous treatment(s):

Size: length 10 cm width 5 cm depth 3 cm

Wound location(s):

Information about location(s):

Pain level:

0 1 2 3 4 5 6 7 8 9 10
No pain Moderate pain Worst pain

If any pain, is it: Constant At dressing changes

 Wound bed assessment
Wound bed Assessment
• Tissue type
• Exudate
• Infection

Wound bed

WOUND

Wound edge Assessment Periwound skin Assessment

Wound edge Periwound skin

Wound bed Assessment

Tissue type
Nectotic √ % Granulating √ %
Sloughy % Epithelialising %

Exudate

Level Dry Low Medium High

Type Thin/watery Cloudy √ Thick Purulent

Clear Pink/red
Infection
Local Spreading/systemic
Increased pain Increased erythema
Erythema Pyrexia
Oedema Abscess/pus
Local warmth Wound breakdown
Increased exudate Cellulitis
Delayed healing General malaise
Friable granulation tissue Raised WBC count
Malodour Lymphangitis
Pocketing

Swab taken: Yes √ No

If yes, result: Date:
Wound edge assessment
Wound bed Assessment

Wound bed

WOUND

Wound edge Assessment WoundPeriwoundAssessmentskinAssessment

• Maceration Wound edge Periwound skin

• Dehydration
• Undermining
• Thickened/rolled edges

Wound edge Assessment

Maceration √ Undermining Mark position of undermining

Dehydration Rolled edges Extent: ____ cm

Periwound skin assessment

WoundAssessmentbedAssessment

Wound bed

Wound edge Assessment WOUND Periwound skin Assessment

• Maceration
• Excoriation
Wound edge Periwound skin
• Dry skin
• Hyperkeratosis
• Callus
• Eczema

Periwound skin Assessment

Maceration √ cm Hyperkeratosis cm
Excoriation cm Callus cm
Dry skin cm Eczema cm

Status
Is the wound: N/A- First visit Deteriorating Static Improving
 Management goals

Tick all appropriate Wound bed Assessment

management goals

Management goals
• Remove non-viable tissue
• Manage exudate
• Manage bacterial burden
Wound bed
• Rehydrate wound bed
• Protect granulation/epithelial tissue

WOUND
Wound edge Assessment Periwound skin Assessment

Wound edge Periwound skin

Management goals Management goals

• Manage exudate • Manage exudate
• Rehydrate wound edge • Protect skin
• Remove non-viable tissue • Rehydrate skin
• Protect granulation/epithelial tissue • Remove non-viable tissue

Wound Management Goals

Type all management goals:

Treatment choice
Treatment:
Dressing type/name: hydrocoloid
Reason for choosing dressing:

Follow up plan
Date of next visit: Main objective at next visit:
Date of reassessment: Refferal needed: Yes No
If yes, to who: Date:

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