Skin Anatomy, Physiology and Wound Healing
Video on Wound Healing: CLICK HERE
Video on Scar Tissue: CLICK HERE
Step 1: Assess and/or Reassess
Tools to Assess Risk of Skin Breakdown
Pressure: Adult
- Norton: CLICK HERE
- MDS InterRAI Crosswalk: CLICK HERE
- Braden Scale: CLICK HERE
- Waterlow Scale: CLICK HERE
Pressure: Pediatric
- Braden Q: CLICK HERE
- Glamorgan Scale: CLICK HERE
- Neonatal Skin Risk Assessment Scale (NSRAS): CLICK HERE
- Waterlow Scale: CLICK HERE
Diabetic Foot Ulcers:
- Inlow 60-Second Diabetic Foot Screen: CLICK HERE
- Self-Assessment Footwear Checklist for Patients: CLICK HERE
Skin Tears:
- ISTAP Risk Assessment Tool: CLICK HERE
Lower Leg:
-
ABPI: CLICK HERE
Wound Assessment Tools
- Bates-Jensen Wound Assessment Tool (BWAT), previously the Pressure Sore Status Tool (PSST): CLICK HERE
- NPUAP Pressure Injury Staging: CLICK HERE
- Leg Ulcer Measurement Tool (LUMT): CLICK HERE
- Pressure Ulcer Scale for Healing (PUSH):CLICK HERE
- Photographic Wound Assessment Tool (PWAT): CLICK HERE
- MEASURE Mnemonic: CLICK HERE
- Bioburden Checklist: CLICK HERE
- ISTAP Skin Tear Classification System: CLICK HERE
- Skin Tear Tool Kit: CLICK HERE
- Barber Measurement Tool (BMT): CLICK HERE
- ASEPSIS Tool: CLICK HERE
- Outcome and Assessment Information Set C (OASIS-C): CLICK HERE
Pain Assessment Tools
- Visual Analogue Scale (VAS): CLICK HERE
- Numeric Rating Scale (NRS): CLICK HERE
- Verbal Rating Scale (VRS): CLICK HERE
- McGill Pain Questionnaire (PRQ): CLICK HERE
- Faces, Legs, Activity, Cry and Consolability (FLACC): CLICK HERE
- Faces Pain Scale-Revised (FPS-R): CLICK HERE
- Neonate Assessment Tool: CLICK HERE
- Non-Communicative Patient’s Pain Assessment Instrument (NOPPAIN): CLICK HERE
- Wong-Baker FACES Scale: CLICK HERE
- WHO Pain Ladder: CLICK HERE
Quality of Life (QoL) and Health-related Quality of Life Assessment (HRQoL) Tools
- Cardiff Wound Impact Schedule: CLICK HERE
- Wound-QoL: CLICK HERE
- Freiburg Life Quality Assessment: CLICK HERE
- The Problem Areas in Diabetes Scale (PAID): CLICK HERE
- The Diabetes Distress Scale: CLICK HERE
- The World Health Organization – WHO-5 Well-being Index:CLICK HERE
- The Hospital Anxiety and Depression Scale (HADS): CLICK HERE
- The Patient Health Questionnaire (PHQ-9):CLICK HERE
- The Centre for Epidemiological Studies-Depression Scale (CES-D): CLICK HERE
- The Beck Depression Inventory: CLICK HERE
Nutritional Screening Tools
- Canadian Nutrition Screening Tool:CLICK HERE
- Mini Nutritional Assessment: CLICK HERE
- Malnutrition Universal Screening Tool (MUST): CLICK HERE
- Canadian Malnutrition Task Force:CLICK HERE
Other
- Surgical Procedure Surveillance Length: CLICK HERE
- Mini Nutritional Assessment: CLICK HERE
- Malnutrition Universal Screening Tool (MUST): CLICK HERE
- Canadian Malnutrition Task Force: CLICK HERE
Step 2: Set Goals
- SMART Principles: CLICK HERE
- ABCDEFs Scheme for Goal Setting:CLICK HERE
Step 3: Assemble the Team
- Pieper Pressure Ulcer Knowledge Test (PPUKT): CLICK HERE
- Team Dynamics: CLICK HERE
Step 4: Implement Plan of Care (Local Wound Care)
- ISTAP Skin Tear Product Selection Guide: CLICK HERE
- RNAO Best Practice Implementation Guide:CLICK HERE
- Five A’s of self-management: CLICK HERE
- Maggot Therapy: CLICK HERE
- Bacterial Balance: CLICK HERE
- Smoking Cessaction: CLICK HERE
Step 5: Evaluate Outcomes
Note: Use assessment tools for comparison to determine if outcomes are being met (see step 1)
- Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT): CLICK HERE
Other Resources
Fall Prevention Programs
- RNAO Guideline: Prevention of Falls and Fall Injuries in the Older Adult: CLICK HERE
- The Timed Up and Go (TUG) Test: CLICK HERE
Wound Prevention
- Veterans Health association (VHA) handbook: CLICK HERE
- Agency for Healthcare Research and Quality (AHRQ) toolkit for PI prevention: CLICK HERE
- Pressure Injury Prevention Points: CLICK HERE
- Safer Healthcare Now! Preventing Surgical Site Infections: Getting Started Kit: CLICK HERE
Patient Resources
- Resources by Wound Type: CLICK HERE
- Incision Care After Surgery:CLICK HERE
- PEP Talk: Diabetes, Healthy Feet and You program (CAWC): CLICK HERE
- Tips for Taking Care of Your Limb: CLICK HERE