Assessment Information

Sensible Care

Wound Assessment & Management Plan

Assessor name: *

Title/Role:

Assessment date: *

Assessors Email: *

Consumers name: *

DOB:

I consent to my/the consumer's wound/s being regularly assessed by a qualified clinician and having photos taken for the purpose of monitoring the healing process.

Person signing

ConsumerRepresentative

Consumers name:

Date:

Consumers signature:

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Representative's name:

Date:

Representative's signature:

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Summary diagnosis/surgical history:

Is the client on blood thinners?

YesNo

Attach Medical Summary (if applicable)

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Allergies

Medication/s:

Food:

Other/s:

Wound Assessment

Wound Type

Other:

Wound Details

Mark the location of the wound on the diagram below:

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Describe the location of the wound:

Initial shape:

Size of Wound

Width (W)mm

Length (L)mm

Depth (D)mm

Tracking/undermining

Odor

Is the wound causing an odor?

YesNo

Describe the odor

Pain

Is the wound causing pain?

YesNo

Pain rating:

When does pain occur?

Dressing changeMovementContinuousOther

Provide further details

Exudate

Amount of Exudate

Colour of Exudate

Pressure Relieving Equipment in Use

Mattress

YesNo

Cushion

YesNo

Heel protection

YesNo

Other

YesNo

Provide further details

Wound Severity

Select the appropriate description/s.

Ulcer:

Superficial Partial thicknessFull thicknessDeep cavity

Burn:

First degreeSecond degreeThird degree

Incontinence Associated Dermatitis:

At riskRed skinBroken skin

Bruise age:

Reddish (initial)Blue or purple (day 1-2)Green (day 6)Yellow-brown (day 8-9)

Treatment Plan

Aims of Treatment

Other:

Treatment Plan

Dressing required:

YesNo

Dressing change frequency:

Primary dressing

Secondary dressing

Cleansing agent:

Bandaging/retention

Comments:

Please tick if you need to notify the GP or appropriate health professional if signs of infection are present e.g. redness, pain, heat, cellulitis, purulent exudate or malodour

Baden Scale for Predicting Pressure Sore Risk

Sensory Perception

Ability to respond meaningfully to pressure-related discomfort

1. Completely Limited - Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of the body2. Very Limited - Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness ORHas a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of the body.3. Slightly Limited - Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.4. No impairment - Responds to verbal commands. Has no sensory deficit which would limit the ability to feel or voice pain or discomfort.

Moisture

Degree to which skin is exposed to moisture

1. Constantly Moist - Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.2. Very Moist - Skin is often, but not always moist. Linen must be changed at least once a shift.3. Occasionally Moist - Skin is occasionally moist, requiring an extra linen change approximately once a day.4. Rarely Moist - Skin is usually dry, linen only requires changing at routine intervals.

Activity

Degree of physical activity

1. Bedfast - Confined to bed.2. Chairfast - Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.3. Walks Occasionally - Walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.4. Walks Frequently - Walks outside room at least twice a day and inside room at least once every two hours during waking hours.

Mobility

Ability to change and control body position

1. Completely Immobile - Does not make even slight changes in body or extremity position without assistance.2. Very Limited - Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.3. Slightly Limited - Makes frequent though slight changes in body or extremity position independently.4. No Limitation - Makes major and frequent changes in position without assistance.

Nutrition

Usual food intake pattern

1. Very Poor - Never eats a complete meal. Rarely eats more than 1/3 of any food offered. East 2 servings or less of protein (meat or dairy products) per day. Does not take a liquid dietary supplement. OR Is NPO and/or maintained on clear liquids or IV's for more than 5 days.2. Probably Inadequate - Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products a day. Occasionally will take a dietary supplement. ORReceives less than optimum amount of liquid diet or tube feeding.3. Adequate - Eats over half of most meals. Eats a total of 4 servings of protein meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered.ORIs on a feeding tube or TPN regimen which probably meets most of the nutritional needs.4. Excellent - Eats most of every meals. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

Score

Please see the Bates-Jensen Wound Assessment Tool

Epithelialization

1 = 100% wound covered, surface intact2 = 75% to <100% wound covered &/or epithelial tissue extends >0.5cm into wound bed3 = 50% to <75% wound covered &/or epithelial tissue extends to <0.5cm into wound bed4 = 25% to < 50% wound covered5 = < 25% wound covered

Score

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Wound Photos

Only pop up photos when one of them is added.

Date:

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Recommendations

Final Draft of the Assessment

Yes

Care Managers Email:Care Managers email address is their first name @sensiblecare.com.au (eg. mary@sensiblecare.com.au)

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