WOUND ASSESSMENT

WOUND ASSESSMENT

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Complete the rating sheet to assess wound status. Evaluate each item by picking the response that best describes the wound and entering the number in the item column for the appropriate date. See "Instructions for Use" to guide you in completing the rating form. Use a separate form for each wound.

Location: Anatomic site. Circle, identify right (R) or left (L) and use "X" to mark site on body diagrams or draw incision on body:

_____ Sacrum and coccyx _____ Ischial tuberosity _____Lateral ankle _____ Incision site

_____ Trochanter _____ Heel _____ Medial ankle _____________ Other site

Shape: Overall wound pattern; assess by observing perimeter and depth.

Circle and date appropriate description:

_____ Irregular _____ Linear or elongated _____ Square/rectangle _____ Butterfly

_____ Round/oval _____ Bowl/boat ___________________Other site

Dressing Order: (include cleansing, product name,
size, if it is a border, rope or gauze product, frequency)
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Dressing Order Change: ______________________
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ITEM	ASSESSMENT	Date	Date	Date	Date	Date
1. Size	Measure length x width and record in the date column in centimeters
2. Depth	Measure in centimeters
3. Edges	1 = Indistinct, diffuse, not clearly visible 2 = Distinct, outline clearly visible, attached, even with wound base 3 = Defined, not attached to wound base 4 = Defined, not attached to base, rolled under, thickened 5 = Defined, fibrotic, scarred, or hyperkeratonic

4. Undermining	1 = < 2 cm in any area 2 = 2 to 4 cm involving < 50% margins 3 = 2 to 4 cm involving > 50% margins 4 = > 4 cm in any area 5 = Tunneling &/or sinus tract formation
5. Necrotic Tissue Type and Amount	1 = None visible INDICATE % OF WOUND INVOLVED NEXT TO NO. IN DATE COLUMN: 2 = White/gray non-viable tissue &/or non-adherent yellow slough 3 = Loosely adherent yellow slough 4 = Adherent, soft black eschar 5 = Firmly adherent, hard black eschar

6. Exudate Type & Amount	Indicate type and amount by placing a number from each column in date column 1 = Bloody 1 = None 2 = Serosanguinous 2 = Scant 3 = Serous * 3 = Small 4 = Purulent * 4 = Moderate 5 = Foul purulent* 5 = Large 6 = None
7. Skin Color Surrounding Wound	1 = Pink or normal for ethnic group 2 = Bright red &/ or blanches to touch 3 = White or gray pallor or hypopigmented 4 = Dark red or purple &/ or non-blanchable* 5 = Black or hyperpigmented

8. Peripheral Tissue Edema	1 = Same 2 = Non-pitting edema extends < 4 cm around wound 3 = Non-pitting edema extends > 4 cm around wound 4 = Pitting edema extends < 4 cm around wound 5 = Crepitus &/or pitting edema extends > 4 cm
9. Peripheral Tissue Induration	1 = Minimal firmness around wound 2 = Induration < 2 cm around wound 3 = Induration 2 to 4 cm extending < 50% around wound 4 = Induration 2 to 4 cm extending > 50%around wound 5 = Induration > 4 cm in any area*

10. Granulation Tissue	1 = Skin intact 2 = Bright beefy red with tissue overgrowth 3 = Bright beefy red 4 = Pink &/or dull; dusky red 5 = No granulation tissue present
11. Infection (must be reflected in other items)	1 = None 2 = Four of the following: a. Heat d. Tenderness/Pain b. Fever e. Serous drainage c. Induration f. Redness of skin 3 = Pus

12. Discomfort: (Record both No. & letter in column)	Scale: 0-5 with 0 being no pain* a. During treatment b. All the time c. During exertion d. When elevated
13. Wound Status	1 = Healing 2 = Unchanged 3 = Deteriorating

14. Stage	Record stage I, II, III or IV for pressure ulcers Only
	INITIALS:

*Infection

Initials and signature

ACWCP - 1998