Wound Assessment & Management Plan XC300340 & … · Wound Pain Score: /10 Score: /10 Score: /10...

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Please use ID Label or block print

_______________________ Hospital / Health Service

Wound Assessment & Management Plan

Ward:

Doctor:

Surname UMRN / MRN

Given Name DOB Gender

Address Postcode

Telephone

Identify location of wound on diagram below. If multiple wounds, use a separate form for each.

Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:

1a 1b 2a 2b 3 Unsure

Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury

Venous Neuropathic Arterial Neuroischaemic Mixed Unsure

ABPI (L): ABPI (R):

Describe:

Factors Impairing Healing:

Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions

Smoking Ischaemia Poor nutrition Medication Other:

Location of Wound:

Assessment Date: Date: Date:

Dimensions Length mm mm mm

Width mm mm mm

Depth mm mm mm Wound Appearance

Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%

Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%

Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)

Wound Edges Pink / Red

Purple / Black Raised

Undermined / Cavity Surrounding Skin

Normal Erythema (redness)

Oedema Dry / Scaly

Fragile / Thin Maceration

Other (specify)

Exudate: Amount and Type Nil Low Mod Heavy

Nil Low Mod Heavy

Nil Low Mod Heavy

Serous (clear / straw) Haemoserous (pale pink / straw)

Purulent (pus, creamy) Sanguinous (bright blood)

Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour

Wound Pain Score: /10 Score: /10 Score: /10

Patient’s description of pain

Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes

Signature & Designation MR

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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy







Signature & Designation

MR

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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








MR

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ound

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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








MR

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ound

Ass

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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








MR

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ound

Ass

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ent &

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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








WMR12208/18 M

R 1

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WMR122 HCWZZFMR0122 FOB BLACK PMS 306


Hospital / Health Service

Doctor:

Ward:

SURNAME

GIVEN NAMES DOB

TELEPHONE

GENDER

ADDRESS POSTCODE

UMRN / MRN

Please use I.D. label or block printH

CW

ZZFM

R01

22

XC

3003

40

Right Right

LeftLeft

RL RL

RL RL

Right Right

LeftLeft

RL RL

RL RL

L R

R L

MR

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Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone






ABPI (L): ABPI (R):

Describe:




Location of Wound:



Width mm mm mm









Oedema Dry / Scaly


Other (specify)


Nil Low Mod Heavy

Nil Low Mod Heavy








Complete Pressure Injury Alert sticker and stick in progress notes

WMR122 HCWZZFMR0122.indd 1 3/8/18 2:01 pm




Ward:

Doctor:

Surname UMRN / MRN


Address Postcode

Telephone

Allergies / Alerts / Skin sensitivities: Referrals sent to:

Plan developed in partnership with Patient/Carer: _____/_____/_____ Patient/Carer Signature: _______________ Frequency (eg daily, 2nd daily): Analgesia prior: Yes No

Goals of care: Moisture balance Bacterial balance Debridement Comfort Other: Cleanse with: N/Saline H2O Other: Care of peri-wound skin:

Primary Dressing:

Secondary Dressing:

Fixation / Bandaging:

Comments:

Name: Signature: Designation:

Date ceased / revised: _____ / _____ / ______ Reason:

Frequency (eg daily, 2nd daily): Analgesia prior: Yes No


Primary Dressing:

Secondary Dressing:


Comments:



Frequency (eg daily, 2nd daily): Analgesia prior: Yes No


Primary Dressing:

Secondary Dressing:


Comments:



Record of Dressing Attended Date Dressing

Attended Date

Next Due Print Name Initials Date Dressing Attended

Date Next Due Print Name Initials

1 7

2 8

3 9

4 10

5 11

6 12 WACHS version 5 November 2015

Plan developed in partnership with Patient/Carer: _____/_____/_____ Patient/Carer Signature: _______________

Plan developed in partnership with Patient/Carer: _____/_____/_____ Patient/Carer Signature: _______________

WACHS version 10 August 2018

WMR122 HCWZZFMR0122 BOB BLACK

SURNAME

GIVEN NAMES DOB

TELEPHONE

GENDER

ADDRESS POSTCODE

UMRN / MRN

Please use I.D. label or block print


Hospital / Health Service

Doctor:

Ward:

WMR122 HCWZZFMR0122.indd 2 3/8/18 2:01 pm

Wound Assessment & Management Plan XC300340 & … · Wound Pain Score: /10 Score: /10 Score: /10...

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