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Wound Care: Assessment Tools

Executive Summary

This article outlines a list of tools designed to help assess and treat wounds. The links will provide examples to wound, pain, quality of life, and nutritional assessment tools. These tools can also help healthcare providers create a plan for approaching wound care.

For more information on wound care: Wound Care Overview

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Risk Assessment Tools

Braden Scale 


Inlow's 60 Second Diabetic Foot Screen 

  • Inlow's 60 Second Diabetic Foot Screen
  • The Inlow tool has been designed so the results from different parameters can be combined to identify for clinicians any pathologies or care deficits that threaten the integrity of the patient’s feet.
  • Using hands, eyes, ears and a monofilament, clinicians can quickly move through the categories. Once each element is assessed, a score is placed in the appropriate space on the patient’s Inlow worksheet. Based on the value entered for each category, the clinician can provide care recommendations specific to each patient’s needs.
  • This tool has undergone rigorous evaluation

Waterlow

  • Waterloo Pressure Ulcer Scale
  • Waterlow Pressure Ulcer 
  • The primary aim of this tool is to assist you to assess the risk of a patient/client developing a pressure ulcer.
  • The tool identifies three 'at risk' categories: a score of 10-14 indicates 'at risk', a score of 15-19 indicates 'high risk', and a score of 20 and above indicates very high risk.
  • Waterlow Scale has demonstrated poor inter-rater reliability, high sensitivity, and low-specificity levels.

Braden Q

  • Braden Q Scale
  • Braden Q Risk Categories 
  • The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool
  • The Braden Q Scale is used for assessing pressure ulcer risk in the pediatric populations including neonates and children older than 8 years.
  • The descriptors have been modified to reflect the developmental needs of the pediatric population and the unique clinical context for neonates, infants, and children in acute care.

Glamorgan 

  • Glamorgan Pressure Injury Risk Assessment
  • The Glamorgan scale is used to help you assess risk of a child developing a pressure ulcer.
  • A child’s risk of developing a pressure injury should be assessed: within 6 hours of admission, re-assessed daily, whenever a child changes unit/area, every time there are significant changes in his/her condition

Neonatal Skill Risk Assessment Scale (NSRAS)


Wound Assessment Tools

Bates-Jensen Wound Assessment Tool (BWAT)

  • Bates Jensen Wound Assessment Tool
  • The Bates-Jensen Wound Assessment Tool formerly known as the Pressure Sore Status Tool 
  • Rate according to each item by picking the response that best describes the wound and entering that score in the item score column for the appropriate date. When you have rated the wound on all items, determine the total score by adding together the 13-item scores.
  • The HIGHER the total score, the more severe the wound status. 
  • Evaluate once a week and whenever a change occurs in the wound.

Leg Ulcer Measurement Tool (LUMT)


Pressure Ulcer Scale for Healing (PUSH)


Photographic Wound Assessment Tool (PWAT)

  • The Photographic Wound Assessment Tool (PWAT)
  • Standardized equipment and a consistent technique should be used with serial wound photography. It must be emphasized, however, that photographs should not replace bedside clinical wound assessment
  • PWAT has been found to be very responsive to change and can be used as a bedside tool, and to assign a score to photographs of a wound 
  • Developed by wound care clinicians and researchers by extracting the Pressure Sore Status Tool subscales that could be evaluated from photographs

Pain Assessment Tools 

The Visual Analogue Scale (VAS)

  • The Visual Analogue Scale (VAS)
  • VAS is a unidimensional measure of pain intensity, which has been widely used in diverse adult populations, including those with rheumatic diseases
  • VAS is more sensitive to small changes than are simple descriptive ordinal scales in which symptoms are rated, for example, as mild or slight, moderate, or severe to agonizing.

Numeric Rating Scale (NRS)

  • Numeric Rating Scale (NRS)
  • The pain NRS is a single 11‐point numeric scale that takes <1 minute to complete.
  • The NRS can be administered verbally (therefore also by telephone) or graphically for self‐completion.
  • However, similar to the pain VAS, the pain NRS evaluates only 1 component of the pain experience, pain intensity, and therefore does not capture the complexity and idiosyncratic nature of the pain experience or improvements due to symptom fluctuations.

Verbal Rating Scale (VRS)

  • Verbal Rating Scale (VRS)
  • VRS adjectives are used to describe different levels of pain.
  • VRS has been shown to correlate strongly with other pain-assessment tools.
  • Compared to other instruments, the respondent’s compliance is often as good or even better even though the subjects must read the entire list before answering, which is time-consuming.

McGill Pain Questionnaire (MPQ)


Faces, Legs, Activity, Cry and Consolability (FLACC)

  • Faces, Legs, Activity, Cry and Consolabilitiy (FLACC)
  • The FLACC-R Scale is used for children older than one year that cannot report their pain. Typically this scale is used for newborn to age 3.
  • Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report is not possible, interpretation of pain behaviors and decisions regarding treatment of pain require careful consideration of the context in which the pain behaviors are observed.

NOPPAIN

  • NOPPAIN
  • Non-Communicative Patient's Pain Assessment Instrument is a nursing assistant-administered instrument for assessing pain behaviors 
  • NOPPAIN has four main sections:
    • Activity Chart Checklist: this is a list of nine care tasks and the rater marks which activities were performed and whether pain was observed.
    • Pain Behavior-Presence: six pain behaviors with graphic illustrations are presented (pain words, pain faces, pain noises, bracing, rubbing, restlessness) and the rater marks those observed.
    • Pain Behavior-Intensity: the rater evaluates the intensity of each pain behavior on a 6-point Likert scale from 0 to 5.
    • Pain Intensity: the rater assesses the highest pain intensity observed in the patient on an 11-point numerical rating scale. 

Neonatal Infant Pain Scale (NIPS)

  • Pain diary 
  • The Neonatal Infant Pain Scale (NIPS) is a behavioral scale and can be utilized with both full-term and pre-term infants.
  • Total pain scores range from 0-7. (0-2 = mild to no pain; 3-4 = mild to moderate pain; 4 – 7 = severe pain)

Quality of Life Tools 

Cardiff Wound Impact Schedule (CWIS)

  • Cardiff Wound Impact Questionnaire
  • Cardiff Wound Impact Schedule
  • This tool is a validated questionnaire that measures the impact of chronic wounds on patient health-related quality of life and identifies areas of patient concern
  • It is a subjective, qualitative measure that generally covers four domains: physical functional status, symptoms and side effects, social functioning and psychological state.

Wound-QoL

  • Quality of Life with Chronic Wounds - Wound-QoL Questionnaire
  • Wound-QoL
  • Wound-QoL is a short questionnaire measuring the quality of life in patients with chronic wounds
  • It consists of 17 items on impairments which are always assessed in retrospect to the preceding seven days.
  • The Wound-QoL can be used in clinical and observational studies and in daily practice.

Freiburg Life Quality Assessment (FLQA)

  • Freiburg Life Quality Assessment
  • The tool is a wound module to measure disease-specific health-related quality-of-life parameters in patients with chronic wounds
  • FLQA includes 53 items referring to 6 dimensions of quality of life

Nutritional Screening Tools

  • Canadian Nutrition Screening Tool
  • Canadian Malnutrition Task Force Resources
  • The CNST is the first valid and reliable tool tested by untrained nursing personnel, which represents the reality of a hospital setting.
  • The CNST is a simple tool that poses 2 questions, and when the answer is “yes” for both questions, a patient is classified at nutrition risk and will require an evaluation by the dietitian.
  • This tool has good sensitivity and specificity to predict adverse outcomes