Wound Assessment Report
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1 Wound Assessment Report Single Assessment, Single Wound Mary Taylor Assessment Patient ID MT Date of Birth Left Foot, Sole: Wound A Image taken Area 1.7cm2 Perimeter 48mm Maximum Depth 7mm Mean Depth 3mm Volume.5cm3 1 Area (last 4 assessments) Area 1.7cm2 cm Page 1
2 MT Mary Taylor Assessment: Depth (last 4 assessments) mm 1 5 Max Depth 7mm Mean Depth 3mm Volume (last 4 assessments) Volume.5cm3 4 cm Patient Notes Medical History Current conditions Cardiac condition;peripheral vascular disease Current conditions: Other Past medical history Contributing factors Edema;Nutritional factors;obesity Smoking;Venous hypertension Contributing factors: Other Comment Wound Etiology Neuropathic Pressure Surgical Burns Cancerous wound Pilonidal wound Skin graft Donor site Wound etiology: Other Wound precursor Trauma Duration of wound at assessment (weeks) 1 Page 2
3 MT Mary Taylor Assessment: Investigation History Diagnostic Venous duplex Comment Pathology Comment Wound Management Supplier Wound product provider Comments Medication Medicines NSAIDS;Anti-coagulants;Beta blockers Medicines: Other Sensitivities: Medicines Sensitivities: Dressings & Adhesives Sensitivities: Other Comment Visit Notes Vital signs Height (cm) 172 Weight (kg) 97 Blood pressure, systolic (mmhg) 155 Blood pressure, diastolic (mmhg) 98 Pulse rate (/min) 72 Respiration rate (/min) 8 Temperature ( C) 37.5 Blood glucose level (mmol/l) 5.5 Related Pain (Non-Wound) Location Occurrence Occurrence: Other Scale (-1) Comments Edema Present Yes Pitting No Location (right) Foot Location (left) Foot Location: Other Comments Lower Limb Assessment Warmth (right leg) Warm Venous signs (right leg) Varicose veins Arterial signs (right leg) Warmth (left leg) Warm Venous signs (left leg) Varicose veins;eczema Arterial signs (left leg) Ambulation Independent with mobility aid or assistance Client report of walking duration (minutes) Calf muscle effectiveness (right) Yes Calf muscle effectiveness (left) Yes Pulses palpable (right) Dorsalis pedis;posterior tibial Dorsalis pedis pressure (right) Posterior tibial pressure (right) Brachial pressure (right) Pulse signal (right) Pulses palpable (left) Dorsalis pedis;posterior tibial Dorsalis pedis pressure (left) Posterior tibial pressure (left) Brachial pressure (left) Pulse signal (left) ABPI result (right) Toe pressure (right) TBPI (right) ABPI result (left) Toe pressure (left) TBPI (left) Thinnest ankle (right) (cm) Widest calf (right) (cm) Thinnest ankle (left) (cm) Widest calf (left) (cm) Comment 1 Page 3
4 MT Mary Taylor Assessment: Factors Affecting Healing Foot Assessment attended Yes Impaired sensation (left) No Impaired sensation (right) No Pain assessment indicated No Pain Assessment attended No Pressure risk assessment attended Braden outcome PURA outcome Nutritional Risk Screening Tool attended Yes Nutritional Risk screen Obvious overweight affecting life quality BMI attended Yes BMI outcome Obese (>3) Does the client smoke Yes Cigarettes per day < 1 Has the client ever smoked Yes Currently taking antibiotics No Purpose for antibiotics Wound Notes Wound Appearance Epithelializing (island) (%) Granulating (%) Sloughy (%) Necrotic (%) Hypergranulating (%) Underlying structures Underlying structures: Other Has the wound healed? No No No No Wound Margins Sloping Yes Yes Yes Yes Punched out No No No No Rolled No No No No Everted No No No No Undermining No No No No Sinus No No No No Inflamed No No Yes Yes Wound margins: Other Surrounding Skin 'Tissue paper' skin No No No No Peri-wound edema Yes Yes Yes Yes Macerated No No Yes Yes Erythema No No No Yes Inflammation No No No No Pustules No No Yes No Eczema No No Yes Yes Dry/scaly No Yes No Yes Healthy Yes No No Surrounding skin: Other Exudate Volume Minimal moisture Minimal moisture Moderately exuding Heavily exuding Type Serous Serous Serous Serous Page 4
5 MT Mary Taylor Assessment: Type: Other Signs of Critical Colonization or Infection Cellulitis No No No No Suppuration No No No No Lymphangitis No No No No Sepsis No No No No Bacteremia No No No No Changes in granulation No No No No Exudate increase/malodor No No No No Wound breakdown/new slough No No No No Impaired/delayed healing No No No No Increase/new pain No No No No Wound Pain Frequency Intermittent Intermittent Intermittent Intermittent Nature of pain Aching Aching Aching;Tender Aching;Tender Nature of pain: Other At dressing change (-1) Night pain (-1) On walking (-1) On elevation (-1) Dependent (-1) Other (-1) Other (description) Current interventions Current interventions: Other Treatment Goal of treatment Absorb exudate Absorb exudate Absorb exudate Technique Clean Clean Clean Primary dressing type Negative pressure Negative pressure Primary dressing product Secondary dressing type Negative pressure Secondary dressing product Compression therapy type 23 mmhg compression 23 mmhg compression 23 mmhg compression 4 mmhg compression Compression therapy product Other compression therapy Adjunct therapy Re-evaluation date Treatment outcome Signature: Name: Signed Date: Page 5
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