NATVNS

WOUND ASSESSMENT
See Guidelines on back page to Complete Form
Affix patient label if available

Factors which could delay healing

(Please tick relevant box)

Name : Unit CHI No : Ward / Address : Consultant / GP : Body Diagram D.O.B. :

Immobility Diabetes Respiratory / Circulatory Disease Wound Infection Oedema

Poor Nutrition Incontinence Anaemia Medication Inotropes Steroids Chemotherapy

Other .................................................................................... Allergies & Sensitivities .......................................................

Feet Diagram
Left Right

Medial L R

Lateral

Lateral

Medial

Mark location with X and number each wound Type of Wound

(tick all relevant boxes) Pressure ulcer Leg ulcer Surgical wound Diabetic ulcer Other, specify

Mark location with X and number each wound Referred to : (tick all relevant boxes)
TVN Physiotherapist Other (please specify) .............................. Dietician Podiatrist

Total number and duration of each type of Wound

........................................ ........................................ ........................................ ........................................ ........................................
1

Equipment required :
Specialist Mattress Cushion Heel Protector Other (please specify) ..............................

Formal Wound Assessment

Complete on initial assessment and reassess if wound bed changes OR 7 - 10 day intervals Use a separate column for individual wounds Number of Wound
Date of Assessment Grade of pressure ulcer (if applicable) Analgesia required (pre-dressing) Wound Dimensions (enter size) Length (cm/mm) Width (cm/mm) Depth (cm/mm) Or trace wound circumference Is wound undermining Is wound tracking Photography Tissue type on wound bed (enter %) Necrotic (Black) Sloughy (Yellow / Green)
% % % % % % % % % % % % % % % % % % % % % %

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

% Granulating (Red) % % % % % % % % % % % Epithelialising (Pink) % Hypergranulation (Red) % % % % % Wound exudate levels and type (tick relevant boxes) * MAY INDICATE INFECTION *

Low Medium High * Exudate - Serous (Straw) Exudate - Haemoserous (Red / Straw) Exudate - Purulent (Green / Brown) * Malodour * Swab obtained Skin surrounding wound (tick relevant box) Macerated * Oedematous * Erythema * Excoriated skin Fragile Dry scaling Healthy / Intact Treatment objectives (tick relevant box) Debridement Absorption Hydration Protection Palliative / Conservative

Assessors Print Initials

Re-assessment Date

Treatment Plan and Evaluation of Care

To be completed when treatment or dressing type altered NB : PRINT INFORMATION
Date Wound Number Treatment Plan & Dressing Type Frequency Evaluation & Rationale for changing dressing type Signature

Wound Assessment Chart Guidelines

The purpose of the wound assessment chart and guidelines is to assist in assessment and documenting of wounds to improve continuity of care and enhance communication. This chart should be used in conjunction with local guidelines.

Page 1 Complete chart as indicated. Ensure all wounds are numbered and type and duration of wound completed. Factors which could delay healing. Complete allergies and sensitivities and include wound products which appear to have caused similar problems.

Page 2 It is advised to use one formal wound assessment for each wound. Use continuation sheets if more than one wound. If infection suspected or signs present consider sending a wound swab to confirm organism. If photograph obtained please ensure consent obtained.

NB. Formal wound assessment is to be completed on initial assessment, when wound bed changes or every 7 10 days (as per page 2).

Page 3 Complete as indicated. Ensure numbers correspond with the wounds taken from the body / feet diagrams on page 1. Please ensure you write in primary, secondary and supplementary dressing where appropriate. Please document care of surrounding skin if appropriate. Use continuation sheets when required. Use this section for any other relevant information eg, antibiotic commenced.

0308WA(775)7 4