Pathway Health Services

Wound Documentation Guidelines

The Following definitions are from the National Pressure Ulcer Advisory Panel up-date 2/2007

Pressure Ulcer Definition Pressure Ulcer Stages

DTI (Deep Tissue Injury): Stage III:
A pressure ulcer is localized Purple or maroon localized area of Full thickness tissue loss. Subcutaneous fat
injury to the skin and/or underlying discolored intact skin or blood-filled blister may be visible but bone, tendon or muscle
due to damage of underlying soft tissue are not exposed. Slough may be present but
tissue usually over a bony
from pressure and/or shear. The area does not obscure the depth of tissue loss.
prominence, as a result of may be preceded by tissue that is painful, May include undermining and tunneling.
pressure, or pressure in firm, mushy, boggy, warmer or cooler as Further description:
combination with shear and/or compared to adjacent tissue. The depth of a stage III pressure ulcer varies
friction. A number of contributing Further description: by anatomical location. The bridge of the
Deep tissue injury may be difficult to nose, ear, occiput and malleolus do not have
or confounding factors are also
detect in individuals with dark skin tones. subcutaneous tissue and stage III ulcers can
associated with pressure ulcers; Evolution may include a thin blister over a be shallow. In contrast, areas of significant
the significance of these factors is dark wound bed. The wound may further adiposity can develop extremely deep stage
yet to be elucidated. evolve and become covered by thin III pressure ulcers. Bone/tendon is not visible
eschar. Evolution may be rapid exposing or directly palpable.
additional layers of tissue even with
optimal treatment.
This staging system should be
used only to describe pressure Stage I: Stage IV:
Intact skin with non-blanchable redness of Full thickness tissue loss with exposed bone,
ulcers. Wounds from other a localized area usually over a bony tendon or muscle. Slough or eschar may be
causes, such as arterial, venous, prominence. Darkly pigmented skin may present on some parts of the wound bed.
diabetic foot, skin tears, tape not have visible blanching; its color may Often include undermining and tunneling.
burns, perineal dermatitis, differ from the surrounding area. Further description:
Further description: The depth of a stage IV pressure ulcer varies
maceration or excoriation should
The area may be painful, firm, soft, by anatomical location. The bridge of the
not be staged using this system. warmer or cooler as compared to adjacent nose, ear, occiput and malleolus do not have
Other staging systems exist for tissue. Stage I may be difficult to detect in subcutaneous tissue and these ulcers can be
some of these conditions and individuals with dark skin tones. May shallow. Stage IV ulcers can extend into
should be used instead. indicate "at risk" persons (a heralding sign muscle and/or supporting structures (e.g.,
of risk) fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon
is visible or directly palpable.
Stage II: UN (Unstageable):
Partial thickness loss of dermis presenting Full thickness tissue loss in which the base
as a shallow open ulcer with a red pink of the ulcer is covered by slough (yellow, tan,
wound bed, without slough. May also gray, green or brown) and/or eschar (tan,
present as an intact or open/ruptured brown or black) in the wound bed.
serum-filled blister. Further description:
Further description: Until enough slough and/or eschar is
Presents as a shiny or dry shallow ulcer removed to expose the base of the wound,
without slough or bruising.* This stage the true depth, and therefore stage, cannot
should not be used to describe skin tears, be determined. Stable (dry, adherent, intact
tape burns, perineal dermatitis, without erythema or fluctuance) eschar on
maceration or excoriation. the heels serves as "the body's natural
*Bruising indicates suspected deep tissue (biological) cover" and should not be
injury removed.
Copyright: NPUAP 2007

©Pathway Health Services - All Rights Reserved - Copy With Permission Only Wound Resource Manual, Third Edition, 2007 Created by Jeri Lundgren, RN, CWS, CWCN

The Indiana Pressure Ulcer Initiative is a health care quality initiative of the Indiana State Department of
Health and the University of Indianapolis Center for Aging & Community. 2009. Version: Oct 5, 2009
 Pathway Health Services
Wound Documentation Guidelines

When charting a description of a pressure ulcer, the following components should be a part of your weekly charting.

1. LOCATION
2. STAGE Pressure ulcers ONLY per NPUAP Definitions on previous page OR for lower extremity
wounds (arterial, venous and neuropathic) use the following definitions:
Partial Thickness – A partial thickness wound is confined to the skin layers; damage does
not penetrate below the dermis and may be limited to the epidermal layers only.
Full-Thickness – A full-Thickness wound indicates that damage extends below the epidermis
and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone,
tendons, etc.).
3. DIMENSIONS: Always measure length, width, and depth and document it in that order. Always
recorded in centimeters.
Length: Longest head-to-toe measurement.
Width: Longest hip-to-hip measurement.
Depth: Is measured by gently inserting a pre-moistened cotton tipped applicator into the deepest
part of the wound. The measurement from the tip of the applicator to the level of the skin surface is
the depth. If too shallow to measure record as “superficial”.
4. UNDERMINING/TUNNELING: Recorded in centimeters. Measurement done as if the resident is on a
clock with the resident’s head at 12 noon.
Undermining: Measure the extent of the undermining clockwise, then the deepest part of the
undermining (i.e., 1.5cm from 2-7 o’clock).
Sinus tracts/Tunneling: Measure the depth of the sinus tract/tunnel and give direction of the sinus
tract/tunnel by the clock method (i.e., 3cm at 3 o’clock). If there is more than one sinus tract/tunnel,
number each clockwise.
5. WOUND BASE DESCRIPTION: describe the wound bed appearance. If the wound base has a mixture
of these, use the percentage of its extent (i.e., the wound base is 75% granulation tissue with 25% slough
tissue).
Granulation: Pink or beefy red tissue with a shiny, moist, granular appearance.
Necrotic/Eschar Tissue: Black or brown tissue that can be dry or moist in appearance
Slough: Yellow to white tissue and may be stringy, thick or moist in appearance
Epithelial: New or pink shiny tissue that grows in from the edges or as islands on the wound
surface.
6. DRAINAGE:
Amount: Scant, moderate, or copious (small, medium, or heavy)
Color/Consistency: Serous, serosanguineous, purulent, or other.
Odor: If present or not
7. WOUND EDGES: Describe area up to 4cm from edge of the wound. Measure in centimeters. Describe
its characteristics (light pink, deep red, purple, macerated, calloused, etc.).
8. ODOR: Present or not
9. PAIN: Associated with the wound. Interventions
10. PROGRESS: Improved, No Change, Stable, or Declined.

©Pathway Health Services - All Rights Reserved - Copy With Permission Only Wound Resource Manual, Third Edition, 2007 Created by Jeri Lundgren, RN, CWS, CWCN

The Indiana Pressure Ulcer Initiative is a health care quality initiative of the Indiana State Department of
Health and the University of Indianapolis Center for Aging & Community. 2009. Version: Oct 5, 2009