Wound Risk Assessment Wound Risk Assessment Wound Risk Assessment Tool Step 1 of 6 16% DemographicsAge*Gender*MaleFemaleOtherHeight (inches)*Weight (lbs)* Activities of Daily Living (ADL) AssistanceBed Mobility (Support)* No setup or physical help Setup help only One person physical assist Two+ person physical assist Did not occur Transfer (Support)* No setup or physical help Setup help only One person physical assist Two+ person physical assist Did not occur Walk in Room (Self)* Independent Supervision Limited Assistance Extensive Assistance Total Dependence Occurred 2 or fewer Did not occur Walk in Corridor (Self)* Independent Supervision Limited Assistance Extensive Assistance Total Dependence Occurred 2 or fewer Did not occur Locomotion off unit (Self)* Independent Supervision Limited Assistance Extensive Assistance Total Dependence Occurred 2 or fewer Did not occur Locomotion off Unit (Support)* No setup or physical help Setup help only One person physical assist Two+ person physical assist Did not occur Dressing (Self)* Independent Supervision Limited Assistance Extensive Assistance Total Dependence Occurred 2 or fewer Did not occur Dressing (Support)* No setup or physical help Setup help only One person physical assist Two+ person physical assist Did not occur Toilet Use (Self)* Independent Supervision Limited Assistance Extensive Assistance Total Dependence Occurred 2 or fewer Did not occur Balance during Transition and WalkingMoving from Seat to Standing* Steady at all times Not steady, but able to stabilize without staff assist Not steady, only able to stabilize with staff assist Did not occur Walking* Steady at all times Not steady, but able to stabilize without staff assist Not steady, only able to stabilize with staff assist Did not occur Moving On and Off Toilet* Steady at all times Not steady, but able to stabilize without staff assist Not steady, only able to stabilize with staff assist Did not occur Surface to Surface Transfer* Steady at all times Not steady, but able to stabilize without staff assist Not steady, only able to stabilize with staff assist Did not occur Limitation in Range of MotionLower Extremity (hip, knee, ankle, foot)* No Impairment Impairment on One(1) side Impairment on Both sides Mobility DevicesCane/Crutch* Yes No Walker* Yes No Wheelchair (manual or electric)* Yes No Urinary ContinenceUrinary Continence* Always continent Occasionally incontinent Frequently incontinent Always incontinent Not rated Bowel ContinenceBowel Continence* Always continent Occasionally incontinent Frequently incontinent Always incontinent Not rated Active Diagnoses in the last 7 daysCancer (with or without metastasis)* Yes No Congestive Heart Failure* Yes No Peripheral Vascular Disease* Yes No Renal Disease* Yes No Wound Infection (Other than feet)* Yes No Diabetes* Yes No Cerebrovascular Disease* Yes No Hemiplegia* Yes No Paraplegia* Yes No Medications ReceivedIndicate whether or not the resident has received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days.Anti-anxiety* Yes No Antidepressant* Yes No Antibiotic* Yes No Diuretic* Yes No
