Clinical features |
Stage |
Exudate amount |
1 = None |
2 = Scant |
3 = Small |
4 = Moderate |
5 = Large |
Skin color surrounding wound |
1 = Pink or normal for ethnic group |
2 = Bright red and/or blanches to touch |
3 = White or gray pallor or hypopigmented |
4 = Dark red or purple and/or nonblanchable |
5 = Black or hypopigmented |
Peripheral tissue edema |
1 = Minimal swelling around wound |
2 = Nonpitting edema extends <4 cm around wound |
3 = Nonpitting edema extends ≥4 cm around wound |
4 = Pitting edema extends <4 cm around wound |
5 = Crepitus and/or pitting edema extends ≥4 cm |
Peripheral tissue induration |
1 = Minimal firmness around wound |
2 = <2 cm around wound |
3 = 2 to 4 cm extending <50 percent around wound |
4 = 2 to 4 cm extending ≥50 percent around wound |
5 = >4 cm in any area |
Granulation tissue |
1 = Skin intact or partial-thickness wound |
2 = Bright, beefy red; 75 to 100 percent of wound filled and/or tissue overgrowth |
3 = Bright, beefy red; <75 percent and >25 percent of wound filled |
4 = Pink and/or dull, dusky red and/or fills ≤25 percent of wound |
5 = No granulation tissue present |
Epithilization |
1 = 100 percent of wound covered, surface intact |
2 = 75 to 100 percent of wound covered and/or epithelial tissue extends >0.5 cm into wound bed |
3 = 50 to 75 percent of wound covered and/or epithelial tissue extends <0.5 cm into wound bed |
4 = 25 to 50 percent of wound covered |
5 = <25 percent of wound covered |