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Wound Prep and Dress Tool

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2Complaint
3Risks
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FOR DEMONSTRATION ONLY! This wound assessment tool is currently being developed and not yet ready for use.

Start Assessment

Has this wound been open for more than 2 weeks?

No, wound has not been open for more than 2 weeks
Yes, wound has been open for more than 2 weeks

Start Assessment

Load Saved Documentation

Wound Location

Scalp

Face

Neck

Arm

Elbow

Hands

Chest

Abdomen

Back

Anogenital

Hip

Buttock

Thigh

Knee

Lower Leg

Foot or toes

Distribution

Symmetric Extremities

Asymmetric extremities

Acral

Dermatomal

Photodistributed

Scattered

Onset

Traumatic

Developed acutely over days to weeks

Developed chronically over months to years

Recurring episodes or relapses

Present at birth

Onset: greater than 6 months

Skin signs & symptoms

Pain: no pain

Pain: burning, heavy sensation, or numbness

Pain: sharp, aching, or throbbing

Pain: increase in frequency or intensity

Pruritus

No pruritus

Sex: Female

Sex: Male

Age: 0-25 years old

Age: 26-50 years old

Age: 51-75 years old

Age: 75+ years old

Ethnicity: Asian

Ethnicity: Black

Ethnicity: Caucasian

Ethnicity: Hispanic

Cachexia

Low BMI less than 20

Nutritional deficiency

Overweight/Obese (BMI greater than 25)

Constitutional: fever, malaise, arthralgia, myalgia

Prolonged standing position

Mobility impairment

Allergies

Medical History

Medical history: History of cancer

Medical history: History of Friction or Shear causing the ulcer

Medical history: History of hardware implantation at site of wound

Medical history: History of organ or bone marrow transplantation

Medical history: History of prolonged surgery (greater than 4h) and/or pressure from diagnostic or therapeutic device

Medical history: History of surgery in or around the wound area

Medical history: History of trauma as a cause of the ulcer

Medical history: Onset of lesion after starting therapy with certain drugs up to 6 months before presentation

Medical History: Recurring miscarriages or premature births

Exposure: Cumulative or intense intermittent sun exposure with increased number of past sunburns and/or tanning bed use

Exposure: History of radiation

Social history/Familial history

Social history: Alcohol usage

Social history: Illicit drugs

Social history: Smoking

Familial atypical multiple mole and melanoma

Family history of dyslipidemia, diabetes, and hypertension

Family history of leg ulcers

Family history of melanoma

Family history of PAD

Adherence/self-care

Adherence/self-care: Adherence to wound care instructions: low

Adherence/self-care: Foot care or shoe fit: inadequate

Adherence/self-care: Inadequate Caregiver support

Angiogenesis inhibitors

Antibiotics

Anticonvulsants

Anti-neoplastic drugs (chemotherapy)

Anti-rheumatoid drugs

Anti-thyroid agents

Colchicine

Heparin

Immunosuppressants

Nonsteroidal anti-inflammatory drugs

Oral Contraceptive Pills

Psychoactive agents

Steroids

Topical antiseptics

Vasoconstrictors

Warfarin

Integumentary: Pigmentary changes

Integumentary: Erythema nodosum

Integumentary: Bowen's disease

Integumentary: Chronic skin inflammation on ulcer site, prior to ulcer

Integumentary: Compromised skin integrity, fragile skin

Integumentary: Cutaneous malignancy

Integumentary: Diabetic foot ulcer (history of)

Integumentary: Excessive moisture

Integumentary: Fair complexion

Integumentary: High numbers of typical nevi

Integumentary: Inherited skin diseases

Integumentary: Nail distrophy with/without nail loss

Integumentary: Pathergy

Integumentary: Personal history of previous melanoma

Integumentary: Photosensitivity

Integumentary: Pressure ulcer (history of)

Integumentary: Senile purpura

Integumentary: Signs of abuse and neglect

Integumentary: Teleangectasia

Integumentary: Venous ulcer (history of)

Cardiovascular (Pain): - Intermittent claudication or ischemic rest pain

Cardiovascular (venous): Chronic Venous Insufficiency

Cardiovascular (venous): Deep venous thrombosis

Cardiovascular: Cerebrovascular disease

Cardiovascular: Clotting/thromboembolic disorders

Cardiovascular: Congestive heart failure

Cardiovascular: Coronary artery disease

Cardiovascular: Hemodynamic Instability

Cardiovascular: Hypercoagulable states

Cardiovascular: Hyperlipidemia

Cardiovascular: Hypertension

Cardiovascular: Hypotension

Cardiovascular: Lower extremity edema

Cardiovascular: Myocardial infarction

Cardiovascular: Myocarditis

Cardiovascular: Peripheral arterial disease

Cardiovascular: Popliteal artery entrapment syndrome

Cardiovascular: Surgery - Coronary artery bypass graft (CABG)

Cardiovascular: Surgery - Peripheral bypass surgery

Cardiovascular: Surgery - Previous vein surgery

HEENT: Auditory impairment

HEENT: Conjunvitivis, episcleritis

HEENT: Diabetes- Visual impairment

HEENT: Nasal Discharge

Respiratory: Asthma

Respiratory: Cough

Respiratory: Dyspnea

Respiratory: History of recent upper respiratory tract infection

Gastrointestinal/Genitourinary

GI: Abdominal pain

GI: Dysphagia

GI: Fecal incontinence

GI: Hepatitis

GI: Inflammatory bowel disease

GI: Liver disease

Genitourinary: Dialysis (w/ without catheter)

Genitourinary: End stage renal disease

Genitourinary: Hematuria

Genitourinary: Renal dysfunction

Genitourinary: Testicular pain with no identifiable cause

Genitourinary: Urinary incontinence (w/ without catheter)

Musculoskeletal

Musculoskeletal: Arthralgia (joint pain)

Musculoskeletal: Lower extremity amputation

Musculoskeletal: Lower extremity trauma/fracture (history of)

Musculoskeletal: Recent onset of arthralgia and/or myalgia

Musculoskeletal: Rheumatoid arthritis/ scleroderma

Musculoskeletal: Spasticity

Neurological: Mononeuritis multiplex

Neurological: Neurological condition that impair mobility

Neurological: Parkinson disease

Neurological: Peripheral Neuropathy

Neurological: Spinal cord injury

Endocrine, Heme, Lymph

Endocrine: Diabetes Mellitus (longer duration)

Endocrine: Diabetes Mellitus (poor glucose control)

Endocrine: Hyperparathyroidism

Endocrine: Hypothyroid disease

Heme/lymph: Anemia

Heme/lymph: Lymphoproliferative disorders

Heme/lymph: Primary lymphedema

Heme/lymph: Secondary lymphedema

Heme/lymph: Thalassemia or Sickle Cell Disease

Heme/lymph: vasoocclusive crisis

Allergy, Immune, Rheumatological

Allergy/immune: HIV

Allergy/immune: Immunosuppression

Allergy/immune: Systemic lupus erythematosus

Rheumatological: Cold intolerance

Rheumatological: occlusive peripheral vascular phenomena

Rheumatological: Rheumatological conditions

Rheumatological: Vasculitis

Infectious: History of COVID-19

Hypoxia

Inspection: No signs or symptoms related to hypoxia

Inspection: Gangrene

Inspection: Ischemic skin changes

Inspection: Skin color- pale, blue or pink (a-v shunts)

Skin temperature: Decreased

Capillary refill: Delayed

Pulses, peripheral: Weak/absent

Buerger sign : Pallor of the foot on elevation and rubor (so-called sunset foot)

TEST: TP/ TBI/ TcPO2/ Doppler - Normal

TEST: TP/ TBI/ TcPO2/ Doppler - Suggestive of ischemia

TEST: TP/ TBI/ TcPO2/Doppler - Suggestive of PAD

TEST: ABI < 0.5

TEST: ABI between 0.5-0.8 - PAD

TEST: ABI between 0.9-1.3 - Normal

Neuropathic

No signs and symptoms of neuropathy

Adherence to offloading: low

Charcot arthropathy (chronic)

Foot: Abnormal toenail growth and appearance

Foot: Foot deformities, calluses, skin fissures, blisters

Neuropathy, autonomic: Dry, cracked, sweaty skin

Neuropathy, motor: Impaired Achilles tendon reflex

Neuropathy, sensory: Loss of protective sensation

Venous Status

No signs of symptoms of venous disease

Stasis dermatitis

Adherence to compression therapy: low

Ankle flare

Atrophie blanche or livedoid vasculopathy

Inverted champagne bottle sign

Lipodermatosclerosis

Thrombophlebitis

Varicose vein

Venous eczema

Edema in lower extremities Edema in the absence of heart failure/other disease

TEST: Duplex ultrasound - venous reflux, obstruction, incompetent valve

Infection

No signs or symptoms related to infection

Local: Erythema greater than 0.5 cm* around the wound

Local: Local swelling or induration

Local: Local tenderness or pain

Local: Local warmth

Local: Pocketing and/or bridging in the wound

Local: Purulent discharge

Spreading: Cellulitis with or without crepitus

Spreading: Lymphangitis

Spreading: Sausage toe

Spreading: Sinus tract formation

Spreading: Swelling of lymph glands

Spreading: Wound breakdown/dehiscence w or w/o satellite lesions

Systemic inflammatory signs

TEST: Probe-to-bone: positive

TEST: Serial radiographs: signs of osteomyelitis

TEST: Serum inflammatory markers: elevated

Pressure

No signs of symptoms of pressure injury

Inadequate offloading with support surface, footwear or device

Discoloration compared to surrounding skin

Epidermal separation revealing a dark wound bed or blood filled blister

Non-blanchable erythema

Malignancy

A lesion that is changing in size, shape, or color, or a new lesion

Bleeding ulcer

Fleshy, soft, granulomatous papules or nodules

Granulating mass of the nail fold or subungueal

Nail: longitudinal melanonychia

Proliferative lesions that resemble a cauliflower or fungus-shaped structure extending beyond the skin surface

Soft tissue mass in or on the skin

Ulcer with partial or full dark pigmentation

Ulcerative lesions are characterized by deep craters with raised margins

Well delineated, pearly translucent, flesh-colored papule or nodule with telangiectasias

Well-demarcated, scaly patch or plaque

Rheumatological

Calcinosis cutis

Cutaneous necrosis in leg, face or ears

Digits: Digital ulcers

Digits: Sclerodactilia

Erythematous macules and papules

Flaccid Blisters

Hemorrhagic lesions

Itching, edema in early stages

Livedo reticularis

Lupus pernio

Nikolsky sign: appearance of new or extension of existing erosion with rubbing of the skin

Nodules: painful cutaneous and subcutaneous nodules

Petechiae

Pitting at fingertips

Plaques: atrophic plaques

Plaques: Smooth plaques

Purpura: Palpable purpura

Purpura: Retiform purpura

Raynaud's phenomenon

Sclerodactyly

Skin thickening or hardening

Ulcer exam: sharply demarcated margins

Urticarial plaques (or wheals) of urticarial vasculitis (UV)

Vesiculobullous lesions

TEST: Cryoglobulins

TEST: Increased ESR, CRP

TEST: Positive Antinuclear Antibody (ANA)

Choose option that best describes worst part of the wound

Black, hard, firmly adherent, black eschar (DRY)

Black, soft, adherent, black eschar (WET)

Yellow, adherent slough (DRY)

Yellow, non-adherent slough or white-grey non-viable tissue

Yellow-Red, mix of slough and pale pink/dusky red granulation

Red, raspberry dark red, hypergranular an/or friable

Red, bright beefy red granulation tissue

Red-Pink, mix of bright beefy red granulation tissue and pink tissue

No wound (intact skin) but abnormalities present (e.g, erythema)

Unknown (predominantly covered with eschar/necrosis)

With bone involvement with or without evidence of bone necrosis

With muscle involvement with or without evidence of muscle necrosis

With fat layer exposed (full thickness skin loss)

Limited to breakdown of skin (partial thickness skin loss)

No wound. Intact skin with erythema or other abnormalities

Quantity: None or minimal (moist but no exudate) (DRY)

Quantity: Light (WET)

Quantity: Moderate (WET)

Quantity: Heavy (WET)

Quantity: Very heavy (WET)

CLICK TO EXPAND

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Risks & Findings

Submit to Wound AI

Caution

"It is important to treat the whole patient and not just the 'hole' in the patient."

Dressing selection is just a small part of wound care. Without a holistic, individualized patient assessment and plan that addresses the cause of the ulcer, patient concerns and local wound care, all clinicians’ efforts may not result in complete and timely healing. Thus, it is strongly recommended that dressings be selected after a holistic patient assessment. Assessment can be performed with WoundReference’s Assessment Tool and other tools.

As part of the assessment, clinicians should determine if the ulcer is:

Healable: ulcer has adequate blood supply; causes and existing cofactors, conditions, or medications that could potentially delay healing have been optimized or ideally corrected.
Maintenance: ulcer is healable but either healthcare system factors or patient- related issues (e.g., patient adherence) are preventing the wound from healing.
Non-healable: ulcer that does not have adequate blood supply to support healing or cause cannot be corrected.
Stalled wound (has not healed in 6 weeks): consult wound specialist

The dressing type will change as the needs of the person and their wound change

Sibbald RG et al. Special considerations in wound bed preparation 2011: an update©. Adv Skin Wound Care. 2011 Sep;24(9):415-36

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