Registered Nurses' Association of Ontario

Pressure Injury Wound Assessment

The measurement and physical assessment of stage 2 and higher pressure injuries should include determinations of the following:

  • Wound location
  • Size of the wound (length, width, depth, undermining, tunnelling, and wound edges)
  • Quality and amount of tissue in the wound bed
  • Peri-wound integrity
  • Exudate (type, amount, and odour). This criterion also applies to stage 1 and deep tissue injury pressure injuries
  • Staging of the pressure injuries (i.e., stage 1, 2, 3, and 4; unstageable; and deep tissue injury pressure injuries)
Clinical Management
Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition
Point of Care Resources