Depth | |||||
d | 0 | No particular skin lesion and no redness | D | 3 | Lesion extends into the subcutaneous tissue |
1 | Persistent redness | 4 | Lesion extends to the muscle, tendon, and bone | ||
2 | Lesion extends into dermis | 5 | Lesion extends into the articular or body cavity | ||
U | It is impossible to measure the depth | ||||
Exudate | |||||
e | 0 | None | E | 6 | Heavy: requires dressing change more than twice a day |
1 | Slight: does not require daily dressing change | ||||
3 | Moderate: requires daily dressing change | ||||
Size | |||||
s | 0 | None | S | 15 | 100 cm2 or larger |
3 | Smaller than 4 cm2 | ||||
6 | 4 cm2 or larger, but smaller than 16 cm2 | ||||
8 | 16 cm2 or larger, but smaller than 36 cm2 | ||||
9 | 36 cm2 or larger, but smaller than 64 cm2 | ||||
12 | 64 cm2 or larger, but smaller than 100 cm2 | ||||
Inflammation/Infection | |||||
i | 0 | None | I | 3 | Clear signs of local infection (e.g., inflammation, pus, and foul smell) |
1 | Signs of inflammation (fever, redness, swelling, and pain around the wound) | 9 | Systemic impact, such as fever | ||
Granulation tissue | |||||
g | 0 | Granulation cannot be assessed because the wound is healed or too shallow | G | 4 | Healthy granulation tissue occupies 10% or more, but less than 50% |
1 | Healthy granulation tissue occupies 90% or more | 5 | Healthy granulation tissue occupies less than 10% | ||
3 | Healthy granulation tissue occupies 50% or more, but less than 90% | 6 | No healthy granulation tissue exists | ||
Necrotic tissue | |||||
n | 0 | None | N | 3 | Soft necrotic tissue exists |
6 | Hard and thick necrotic tissue is attached to the wound | ||||
p | 0 | None | P | 6 | Smaller than 4 cm2 |
9 | 4 cm2 or larger, but smaller than 16 cm2 | ||||
12 | 16 cm2 or larger, but smaller than 36 cm2 | ||||
24 | 36 cm2 or larger |