Foul wound odor (110317)
|
Presence of unpleasant odor that exhales from the injury. |
Extensive (1): Extremely stinking wound, with perceptible smell when entering the room |
Substantial (2): Very stinking wound with perceptible odor on removal of secondary cover |
Moderate (3): Foul-smelling wound, perceptible odor at removal of primary cover |
Limited (4): Slightly stinking wound, odor only perceptible when cleaning |
None (5): Odorless wound |
Blistered skin (110310)
|
Superficial elevations, over 1 cm, formed by liquids in a cavity inside the skin. |
Extensive (1): Skin with several blisters covering the entire length of the bed and the edges of the lesion |
Substantial (2): Skin with several blisters covering part of the bed and the edges of the lesion |
Moderate (3): Skin with one or more blisters covering only the edges of the lesion |
Limited (4): Skin with a blister on the injury bed |
None (5): Blister-free skin |
Macerated skin (110311)
|
Whitish tissue, softened or ruptured skin due to excessive hydration. |
Extensive (1): Extensive tissue maceration around the lesion 100% -75% |
Substantial (2): Great maceration 75-50%. |
Moderate (3): Average maceration 50%-25% |
Limited (4): Small maceration 25%- 0% |
None (5): Unstained Skin |
Undermining (110315)
|
Condition of separation or distance of the tissue (s) from the bed under the edges of the lesion. |
Extensive (1): Extensive detachment area under the edges of the lesion 100% -75% |
Substantial (2): Large area of detachment under the edges of the lesion 75%-50%. |
Moderate (3): Average detachment area under the edges of the lesion 50%-25% |
Limited (4): Small detachment area under the edges of the lesion 25% -0% |
None (5): Tissue without detachment |
Wound inflammation (110322)
|
Healing phase with infiltration of neutrophils, macrophages and lymphocytes. |
Extensive (1): Extensive area of inflammation (redness, heat, pain) in the lesion 100% -75% |
Substantial (2): Large area of inflammation 75%-50%. |
Moderate (3): Average area of inflammation 50%-25% |
Limited (4): Small area of ignition 25% - 0% |
None (5): Injury without inflammation |
Exudate/drainage
|
Aqueous content from the lesion composed of cells, protein content and dead microorganisms. |
Extensive (1): Purulent exudate (green or brown aqueous) |
(110303-304-305-306)
|
Substantial (2): Bloody exudate (aqueous) |
|
Moderate (3): Serum exudate (aqueous or yellowish-pink colored liquid) |
|
Limited (4): Serous exudate (yellowish aspect) None (5): Absence of exudate |
Granulation (110301)
|
Vivid red tissue with shiny appearance due to the circulation of red blood cells. |
None (1): No granulation tissue |
Limited (2): 0-25% PI granulation area |
Moderate (3): Granulation area of 25-50% PI |
Substantial (4): Granulation area of 50-75% of PI |
Extensive (5): 75-100% PI granulation area |
Tunneling (110314)
|
Creation of an artificial conduit within the lesion. |
Extensive (1): tunnel >10cm in lesion |
Substantial (2): tunnel between 9 > 7cm in the lesion |
Moderate (3): tunnel between 6 > 4cm in lesion |
Limited (4): tunnel between 3 > 1cm in lesion |
None (5): No tunnel |
Scar formation (110320)
|
Wound covered with epithelial tissue in a pinkish color that develops from the edge. |
None (1): Absence of epithelial tissue |
Limited (2): Area of epithelial tissue of 0-25%. |
Moderate (3): Area of epithelial tissue 25-50%. |
Substantial (4): Area of epithelial tissue 50-75%. |
Extensive (5): Area of epithelial tissue from 75-100%. |
Decreased wound size (110321)
|
Wound area: greatest length versus greatest width (cm2) |
None (1): No reduction in the size of the injury |
Limited (2): Small 0%-25% reduction |
Moderate (3): Average reduction of 25%-50% |
Substantial (4): Large reduction of 50%-75% |
Extensive (5): Virtually closed lesion 75%-100% |