Depth/tissues involved |
Dermis–epidermis involved |
26 (76·5) |
Subcutaneous tissue involved |
8 (23·5) |
Edges |
Not distinguishable (not wound edges) |
1 (2·9) |
Diffuse |
5 (14·7) |
Delimited |
20 (58·8) |
Damaged |
6 (17·6) |
Thickened (‘aged’, ‘reverted’) |
2 (5·9) |
Wound dimensions |
<4 cm2 |
16 (47·1) |
4 ‐ < 16 cm2 |
15 (44·1) |
16 ‐ < 36 cm2 |
2 (5·9) |
64 ‐ < 100 cm2 |
1 (2·9) |
Type of tissue in the wound bed |
Epithelial tissue |
2 (5·9) |
Granulation tissue |
7 (20·6) |
Necrotic tissue and/or slough in the bed |
25 (73·5) |
Exudate |
Moist |
15 (44·1) |
Wet |
10 (29·4) |
Saturated |
5 (14·7) |
Dry |
2 (5·9) |
Leaking exudate |
2 (5·9) |
Infection–inflammation (Biofilm signs) |
Increasingly painful |
21 (61·8) |
Erythema around the wound |
13 (38·2) |
Oedema around the wound |
13 (38·2) |
Rising temperature |
5 (14·7) |
Increasing exudate |
14 (41·2) |
Purulent exudate |
4 (11·8) |
Tissue is friable or bleeds easily |
8 (23·5) |
Wound stationary, no progress |
25 (73·5) |
Tissue compatible with biofilm |
12 (35·3) |
Odour |
10 (29·4) |
Hipergranulation |
8 (23·5) |
Wound increasingly larger |
10 (29·4) |
Satellite lesions |
11 (32·4) |
Pale tissue |
3 (8·8) |