Additional Best Practice Resources

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