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Form 2

Wound Assessment: Ulcer Information


Patient ID:

Facility Name  _______________________________________

Date of Admission: __  __ /__  __ /__  __ __ __
                                    M  M      D    D    Y     Y   Y    Y

Resident ID: _____________________________________

Date Ulcer Identified: MM/DD/YYYY

Initial Stage:
(at time ulcer first identified)

I __  II ___  III ___  IV ___  
Unstageable ___

Multiple Ulcers ID Number

Multiple Ulcer ID: Ulcers will be uniquely identified for reporting. Use this section if you can answer 'yes' to 1 AND 2 below:
1. There are two or more ulcers on the same ulcer location and
2. Multiple ulcers on the same location were identified on the same date, e.g. same onset date

____
Condition:  
New ___ 
 Reopened ___		 Occurrence:  
Admission ___ 
 In-House Acquired ___
Site of Ulcer:
Report Date M|M|D|D M|M|D|D M|M|D|D M|M|D|D M|M|D|D M|M|D|D
Report Type: Please select the report type: (Initial (I), Followup (F)) I F I F I F I F I F I F
Ulcer Dimensions: (Enter ulcer length once; use method used at your facility, clock or longest aspect, and enter in appropriate space)
Length (clock method) cm.            
Length (longest aspect of the wound) cm.            
Width (perpendicular widest width of ulcer) cm.            
Depth cm.            
Wound Edges
1= Indistinct, diffuse, none clearly visible            
2= Distinct, outline clearly visible, attached, even with wound base            
3= Well-defined, not attached to wound base            
4= Well-defined, not attached to base, rolled under, thickened            
5= Well-defined, fibrotic, scarred, hyperkeratotic            
Undermining
Undermining Direction (O’clock)            
Undermining Length (cm.)            
1= Nonpresent            
2= Undermining < 2 cm in any area            
3= Undermining 2-4 cm involving < 50% wound margins            
4= Undermining 2-4 cm involving > 50% wound margins            
5= Undermining > 4 cm or tunneling in any area            
Tunneling
Tunneling Direction (O’clock)            
Tunneling Length (cm)            
Necrotic Tissue Type
1= None visible            
2= White/gray nonviable tissue &/or nonadherent yellow slough            
3= Loosely adherent yellow slough            
4= Adherent, soft, black eschar            
5= Firmly adherent, hard, black eschar            
Necrotic Tissue Amount
1= Nonvisible            
2= < 25 % of wound bed cover            
3= 25% - 50% wound covered            
4= >50% and < 75 % of wound covered            
5= 75% - 100% of wound covered            
Enter Necrotic tissue amount (enter % if 1-5 above not used at your facility)            
Drainage/exudate Type
1= None            
2= Bloody            
3= Serosanguineous: thin, watery, pale red/pink            
4= Serous: thin, watery, clear            
5= Purulent: thin or thick, opaque, tan/yellow, without odor            
6= Purulent: thin or thick, opaque, tan/yellow, with odor            
Drainage/exudate Amount
1= None, dry wound            
2= Scant, wound moist but no observable exudate            
3= Small            
4= Moderate            
5= Large            
Peripheral Wound Area
1= Pink or normal for ethnic group            
2= Bright red &/or blanches to touch            
3= White or gray pallor or hypopigmented            
4= Dark red or purple &/or nonblanchable            
5= Black or hyperpigmented            
Peripheral Wound edema
1= No swelling or edema            
2= Nonpitting edema extends < 4 cm around wound            
3= Nonpitting edema extends > or = 4 cm around wound            
4= Pitting edema extends < 4 cm around wound            
5= Crepitus and/or pitting edema extends > or = 4 cm around wound            
Peripheral Wound induration
1= Not present            
2= Induration < 2 cm around wound            
3= Induration 2-4 cm extending < 50% around wound            
4= Induration 2-4 cm extending > or = 50% around wound            
5= Induration > 4 cm in any area around wound            
Granulation
1= Skin intact or partial thickness wound            
2= Bright, beefy red; 75%-100% of wound filled &/or tissue overgrowth            
3= Bright, beefy red; < 75% and > 25% of wound filled            
4= Pink, &/or dull dusky red &/or fills < or = 25% of wound            
5= No granulation tissue present            
Enter Granulated Amt (enter % if 1-5 above not used at your facility            
Epithelialization
1= 100% wound covered, surface intact            
2= 75% to < 100% wound covered &/or epithelial tissue extends > 0.5 cm into wound bed            
3= 50% to < 75% wound covered &/or epithelial tissue extends to < 0.5 cm into wound bed            
4= 25% to < 50% wound covered            
5= < 25% wound covered            
Pain
Is the ulcer site painful? Select 0-10 on pain scale.            
Pain medication given for ulcer pain            

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