1) Size of the wound in length, width and depth using paper tape to measure. Here are some pointers for all wounds, even if asymmetric:
Use the clockface as the reference for communication and documentation. Use the head and feet as reference points for 12 o’clock and 6 o’clock respectively
Measure caudal-cranial width across longest part
Measure lateral width across the longest part
Measure depth of the wound with cotton swab or finger gently placed to base of wound bed
Note degree to which deeper tissues such as tendon and bone can be visualized
Use the cotton swab to measure depth of undermining and note extent along the clock-face. In addition, use the cotton swab to measure the depth of tunneling. Be as descriptive as possible; for example, “Undermining from 2 o’clock to 6 o’clock with maximum depth of 3cm at 4 o’clock and minimum of 0.5 cm at 2 and 6 o’clock”.
2) Determine the percentage of slough and necrosis
3) Note degree of exudate as mild, moderate or heavy and the quality as serous, purulent or bloody
4) Document the quality and extent of peripheral wound bed or periwound including:
Degree and extent of maceration
Erythema, hyperpigentation, bruising, tenderness, crepitus or fluctuance
Surrounding scar tissue
5) Classify wound as the most advanced stage by depth-- DO NOT reclassify as they heal. For example, as a Stage III pressure ulcer becomes more shallow, it should be described as a “healing stage III ulcer”, not reclassified as a Stage I or II ulcer