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