Patient s Full Name: Date of Birth: NHS Number:

Transcription

1 All sections must be completed. If not relevant please score a line through the appropriate section and state N/A Factors that may delay healing for this patient (If applicable) Infection Dermatological Condition Anaemia Overweight Diabetes Vascular Disease Malnutrition MUST score Immuno Suppressed Treatment discussed and agreed with patient Yes No If no, please specify:- Allergies, please specify e.g. Dressings / creams / latex One, One Assessment Form Location Location Location Location Yes Yes Yes Yes Photographed Yes No Photographed Yes No Photographed Yes No Photographed Yes No Consent form signed for Consent form signed for Consent form signed for Consent form signed for photography Yes No photography Yes No photography Yes No photography Yes No Max Length (mm) Max Length (mm) Max Length (mm) Max Length (mm) Max Width (mm) Max Width (mm) Max Width (mm) Max Width (mm) Depth (mm) Depth (mm) Depth (mm) Depth (mm) Pressure ulcer (PU) Pressure ulcer Pressure ulcer Pressure ulcer (weeping) (weeping) (weeping) (weeping) Page 1 of 5

2 Date & Time (24hrs) Date & Time (24 hrs) Date & Time (24 hrs) Date & Time (24 hrs) < 1-2 weeks 2-4 weeks 1-3 months 3-6 months 6-12 months 1-2 years 2-5 years > 5 years <1-2 weeks 2-4 weeks 1-3 months 3-6 months 6-12 months 1-2 years 2-5 years >5 years <1-2 weeks 2-4 weeks 1-3 months 3-6 months 6-12 months 1-2 years 2-5 years >5 years <1-2 weeks 2-4 weeks 1-3 months 3-6 months 6-12 months 1-2 years 2-5 years >5 years Not Known Not Known Details (Approximate) Not Known Not Known Necrotic (black/brown) Necrotic (black/brown) Necrotic (black/brown) Necrotic (black/brown) Sloughy (cream/yellow) Sloughy (cream/yellow) Sloughy cream/yellow) Sloughy (cream/yellow) Granulating (red) Granulating (red) Granulating (red) Granulating (red) Epitheliaising (pink) Epitheliaising (pink) Epitheliaising (pink) Epitheliaising (pink) Present: Yes No Local Systemic Both Abscess / pus Increased pain Increased exudate Tissue / bleeds easily Evidence of tracking Temperature Present: Yes No Local Systemic Both Abscess / pus Increased pain Increased exudate Tissue / bleeds easily Evidence of tracking Temperature Present: Yes No Local Systemic Both Abscess / pus Increased pain Increased exudate Tissue / bleeds easily Evidence of tracking Temperature Present: Yes No Local Systemic Both Abscess / pus Increased pain Increased exudate Tissue / bleeds easily Evidence of tracking Temperature Date swab taken: Date swab taken: Date swab taken: Date swab taken: Pseudomonas Haemolytic strep A Staph. Aureus, please state: Pseudomonas Haemolytic strep A Staph. Aureus, please state: Pseudomonas Haemolytic strep A Staph. Aureus, please state: Pseudomonas Haemolytic strep A Staph. Aureus, please state: Page 2 of 5

3 Not applicable Yes No Decolonisation therapy Antibiotic therapy Not applicable Yes No Decolonisation therapy Antibiotic therapy Not applicable Yes No Decolonisation therapy Antibiotic therapy Not applicable Yes No Decolonisation therapy Antibiotic therapy Yes No Yes No Yes No Yes No Pain Frequency: please tick At dressing change Post Dressing At dressing change Post Dressing At dressing change Post Dressing At dressing change Post Dressing Yes No If no, Refer back to GP Yes No If no, Refer back to GP Yes No If no, Refer back to GP Yes No If no, Refer back to GP Adhesive remover Alternative Dressing Adhesive remover Alternative Dressing Adhesive remover Alternative Dressing Adhesive remover Alternative Dressing Page 3 of 5

4 detail / scaly Treatment Details / scaly / scaly / scaly Protease Modulating Matrix Protease Modulating Matrix Protease Modulating Matrix Protease Modulating Matrix Renasys pump Renasys pump Renasys pump Renasys pump ordered from CES Yes No Date ordered: ordered from CES Yes No Date ordered: ordered from CES Yes No Date ordered: ordered from CES Yes No Date ordered: Referral required Yes No Referral required YesNo Referral required Yes No Referral required Yes No TVS GP Podiatrist Infection control TVS GP Podiatrist Infection control TVS GP Podiatrist Infection control TVS GP Podiatrist Infection control Treatment No need to write dressing selection on care plan - complete section below Barrier Emollient Barrier Emollient Barrier Emollient Barrier Emollient Topical Preparation Topical Preparation Topical Preparation Topical Preparation Designation Designation Designation Designation Page 4 of 5

5 If there is a clinical need to reassess wound (s), please complete new body map (number each wound) Medial Aspect of Leg Assessors Name Signature Designation Date & Time (24hrs) This assessment form is supported by a generic wound management care plan. This Body Chart can be used to record any markings to skin (Please indicate type of mark next to body part e.g. rash, bruising, injuries) Page 5 of 5