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 helpSetup help onlyOne person physical assistTwo+ person physical assistDid not occurTransfer (Support)*No setup or physical helpSetup help onlyOne person physical assistTwo+ person physical assistDid not occurWalk in Room (Self)*IndependentSupervisionLimited AssistanceExtensive AssistanceTotal DependenceOccurred 2 or fewerDid not occurWalk in Corridor (Self)*IndependentSupervisionLimited AssistanceExtensive AssistanceTotal DependenceOccurred 2 or fewerDid not occurLocomotion off unit (Self)*IndependentSupervisionLimited AssistanceExtensive AssistanceTotal DependenceOccurred 2 or fewerDid not occurLocomotion off Unit (Support)*No setup or physical helpSetup help onlyOne person physical assistTwo+ person physical assistDid not occurDressing (Self)*IndependentSupervisionLimited AssistanceExtensive AssistanceTotal DependenceOccurred 2 or fewerDid not occurDressing (Support)*No setup or physical helpSetup help onlyOne person physical assistTwo+ person physical assistDid not occurToilet Use (Self)*IndependentSupervisionLimited AssistanceExtensive AssistanceTotal DependenceOccurred 2 or fewerDid not occur Balance during Transition and WalkingMoving from Seat to Standing*Steady at all timesNot steady, but able to stabilize without staff assistNot steady, only able to stabilize with staff assistDid not occurWalking*Steady at all timesNot steady, but able to stabilize without staff assistNot steady, only able to stabilize with staff assistDid not occurMoving On and Off Toilet*Steady at all timesNot steady, but able to stabilize without staff assistNot steady, only able to stabilize with staff assistDid not occurSurface to Surface Transfer*Steady at all timesNot steady, but able to stabilize without staff assistNot steady, only able to stabilize with staff assistDid not occurLimitation in Range of MotionLower Extremity (hip, knee, ankle, foot)*No ImpairmentImpairment on One(1) sideImpairment on Both sidesMobility DevicesCane/Crutch*YesNoWalker*YesNoWheelchair (manual or electric)*YesNo Urinary ContinenceUrinary Continence*Always continentOccasionally incontinentFrequently incontinentAlways incontinentNot ratedBowel ContinenceBowel Continence*Always continentOccasionally incontinentFrequently incontinentAlways incontinentNot rated Active Diagnoses in the last 7 daysCancer (with or without metastasis)*YesNoCongestive Heart Failure*YesNoPeripheral Vascular Disease*YesNoRenal Disease*YesNoWound Infection (Other than feet)*YesNoDiabetes*YesNoCerebrovascular Disease*YesNoHemiplegia*YesNoParaplegia*YesNo 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*YesNoAntidepressant*YesNoAntibiotic*YesNoDiuretic*YesNo
