Wound Assessment form

Date: Patient Name:

Patient ID: Assessor Name:

Patient
Age: years
Weight: kgs
Gender: Male Female

Nutrition status: Well nourished Malnourished

Mobility status: Good Mobility Bad Mobility
Smoking: Yes No
If yes, how many/day:

Alcohol: Yes No
If yes, units/week:

Co-morbidities: Venous disease Arterial disease

Diabetes Anaemia

Other:
Medications:
Allergies:
ABPI (done): Yes No
If yes,measurement:
Date:
Wound description
Wound type(s):
Duration of wound(s):
Previous treatment(s):

Size: length mm width mm depth mm

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 Necrotic % G
Sloughy % Ep
Wound bed

Level Dry Low

WOUND
Type Thin/watery
Purulent
Wound edge Assessment Periwound skin Assessment
Wound edge Periwound skin
Local
Increased pain
Erythema
Oedema
Local warmth
Increased exudate
Delayed healing

Necrotic % Granulating %
Friable granulation tissue
Malodour

Wound bed Assessment Pocketing

Sloughy
Tissue type
% Epithelialising %
Necrotic % Granulating %
Nectotic % Granulating %
Sloughy % Epithelialising %
Sloughy % Epithelialising %

Exudate
Level Dry Low Medium High

Level
Type Level
Thin/watery Dry Thick Low
Dry Low
Cloudy Medium Medium High
High
Purulent Clear Pink/red
Type Thin/watery Cloudy Thick Purulent

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

Erythema
Friable granulation tissue Raised WBC count Pyrexia
Malodour Lymphangitis
Pocketing Oedema Abscess/pus
Swab taken: LocalYeswarmth No Wound breakdown
If yes, result: Date:
Increased exudate Cellulitis
Delayed healing General malaise
Friable granulation tissue Raised WBC count
 Wound edge Wou
Wound edge assessment
Wound bed Assessment Maceration

Dehydration

Wound bed
Undermining

Wound edgeWOUND
Wound Assessment
Rolled edges

Wound edge Assessment Wound Assessment

Periwound skin Assessment
d Assessment • Maceration Wound edge
Maceration Periwound skin

• Dehydration
• Undermining
• Thickened/rolled edges

Dehydration

Wound edge Assessment

Wound edge Wound Assessment

Maceration
Maceration
Undermining
Undermining
Mark position of undermining
Dehydration Rolled edges Extent: ____ cm

Dehydration
Rolled edges

ssment
skin Assessment
Undermining

Periwound skin assessment Periwound skin Wou

Rolled edges
WoundAssessment
Wound bed Assessment
Maceration

Excoriation

Wound bed

Dry skin

Wound edge Assessment WOUND

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

Periwound skin Assessment

Periwound skin Wound Assessment

Maceration Maceration cm CM Hyperkeratosis cm

Excoriation cm Callus cm
ExcoriationDry skin cm CM Eczema cm

Dry skin CM
Status
Is the wound: N/A- First visit Deteriorating Static Improving
Hyperkeratosis CM

Callus CM

Eczerma CM
 Management goals
Tick all appropriate Wound bed Assessment
management goals

Management goals
• Remove non-viable tissue
• Manage exudate
• Manage bacterial burden
• Rehydrate wound bed
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:
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:

Coloplast A/S, Holtedam 1, 3050 Humlebaek, Denmark www.coloplast.com

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