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Appendix 7: Weekly Wound Care Progress Note

Introduction

Patient              Room #:     Age:

Name: ___________________________________________________ ______________ _________

For Wound Tracing—See Attached Diagram

Pressure Sore Status Tool

Complete the rating sheet to assess pressure sore status. Evaluate each item by picking the response that best describes the wound and entering the score in the item score column for the appropriate date.

Location: Anatomic Site. Circle, identify right (R) or left (L) and use "X" to mark site on body diagrams:

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Item Assessment #1 #2 #3
  Score Score Score
1. Size

1 = Length × width < 4 sq cm

2 = Length × width 4–16 sq cm

3 = Length × width 16.1–36 sq cm

4 = Length × width 36.1–80 sq cm

5 = Length × width > 80 sq cm

      
2. Depth

1 = Non-blanchable erythema on intact skin

2 = Partial thickness skin loss involving epidermis and/or dermis

3 = Full thickness skin loss involving damage or necrosis of subcutaneous tissue; may extend down to but not through underlying fascia; and/or mixed partial and full thickness and/or tissue layers obscured by granulation tissue.

4 = Obscured by necrosis

5 = Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures

      
3. 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 wound base, rolled under, thickened

5 = Well-defined, fibrotic, scarred or hyperkeratotic

      
4. Undermining

1 = Undermining < 2 cm in any area

2 = Undermining 2–4 cm involving < 50% wound margins

3 = Undermining 2–4 cm involving > 50% wound margins

4 = Undermining > 4 cm in any area

5 = Tunneling and/or sinus tract formation

      
5. Necrotic Tissue Type

1 = Non visible

2 = White/gray non-viable tissue and/or non-adherent yellow

3 = Loosely adherent yellow slough

4 = Adherent, soft, black eschar

5 = Firmly adherent, soft, black eschar

      
6. Necrotic Tissue Amount

1 = Non visible

2 = < 25% of wound bed covered

3 = 25% to 50% of wound covered

4 = > 50% and < 75% of wound covered

5 = 75% to 100% of wound covered

      
7. Exudate Type

1 = None or bloody

2 = Serosanguineous: thin, watery, pale red/pink

3 = Serous: thin, watery, clear

4 = Purulent: thin or thick, opaque, tan/yellow

5 = Foul purulent: thick, opaque, yellow/green with odor

      
8. Exudate Amount

1 = None

2 = Scant

3 = Small

4 = Moderate

5 = Large

      
9. Skin Color Surrounding Wound

1 = Pink or ...

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