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Pressure Sores (Ulcer) Characteristics Cheat Sheet by

ulcer     decubitus

ULCER DIMENS­IONS:

Length (clock method) cms
Length (longest aspect of the wound) cms
Width (perpe­ndi­cular widest width of ulcer) cms
Depth (of the wound) cms

Wound Edges

1 = Indist­inct, diffuse, none clearly visible
2 = Distinct, outline clearly visible, attached, even with wound base
3 = Well-d­efined, not attached to wound base
4 = Well-d­efined, not attached to base, rolled under, thickened
5 = Well-d­efined, fibrotic, scarred, hyperk­era­totic

Underm­ining

Underm­ining Directions (O’clock)
Underm­ining Length (cm)
1 – Non-pr­esent
2 = Underm­ining < 2 cm in any area
3 = Underm­ining 2-4 cm < 50% wound margins
4 = Underm­ining 2-4 cm involving > 50% wound margins
5 = Underm­ining > 4 cm or tunneling in any area

Tunneling

Tunneling Direction (O’clock)
Tunneling Length (cm)

Necrotic Tissue Type

1 = None visible
2 = White/gray non-viable tissue­/&/or non-ad­herent yellow slough
3 = Loosely adherent yellow slough
4 = Adherent, soft, black, eschar
5 = Firmly adherent, hard, black eschar

Necrotic Tissue Amount

1 = Non visible
2 = < 25^ of wound bed covered
3 = 25% - 50% wound covered
4 = =>50% and <75 % of wound covered
5 = 75% - 100% of wound covered
Enter Necrotic tissue amount (enter % if 1-5 above not used at your facility)

Drainage Exudes Amount

1 = None, dry wound
2 = Scant, wound moist but no observable exudate
3 = Small
4 = Moderate
5 = Large
 

Drainage Exudate type

1 = None
2 = Bloody
3 = Serios­ang­uin­eous: thin, watery, pale red/pink
4 = Serious: thin, watery, clear
5 = Purulent: thin or thick, opaque, tan/ye­llow, without odor
6 = Purulent: thin or thick, opaque, tan/ye­llow, with odor

Peri Wound Area

1 = Pink or normal for ethnic group
2 = Bright red &/or blanches to touch
3 = White or grey pallor or hypopi­gmented
4 = Dark red or purple &/or Non-bl­anc­hable
5 = Black or hypopi­gmented

Peri Mound Edema

1 = No swelling or edema
2 = Non-pi­tting edema extends < 4cm around wound
3 = Non-pi­tting edema extends > 4cm around wound
4 = Pitting edema extends < 4cm around wound
5 = Crepitus &/or pitting edema extends > = 4cm around wound

Peri Wound Induration

1 = Non present
2 = Induration < 2cm around wound
3 = Induration 2-4cm extending < 50% around wound
4 = Induration 2-4cm extending >= 50% around wound
5 = Induration > 4cm in any area around wound

Granul­ation

1 = Skin intact or partial thickness wound
2 = Bright, beefy red; < 75% - 100% wound filled &/or tissue over-g­rowth
3 = Bright, beefy red; < 75% and > 25% of wound
4 = Pink, &/or dull dusky red &/or fills < = 25% of wound
5 = No granul­ation tissue present
Enter Granulated Amt (enter % if 1-5 above not used at your facility)

Epithe­lia­liz­ation

1 = 100% wound covered, surface intact
2 = 75% to <100% wound covered &/or epithelial tissue extends > 0.5cm into wound bed
3 = Bright, beefy red; < 75% and > epithelial tissue extends > 0.5 cm into wound bed
4 = 25% to < 50% wound covered
5 = < 25% wound covered

Pain

Is the PU site Painful? Select 1-10 of pain scale

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