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Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Other Descriptors

Wound Assessment Other Descriptors

Good wound management and appropriate dressing selection relies on the comprehensive assessment of all characteristics of the wound and surrounding skin.

Also see Red Flag: Wound Infection

Peri-wound condition

  • Healthy and intact
  • Fragile/ skin tearing
  • Bruised
  • Dry/ cracking/ desiccated
  • Dermatitis
    Periwound dermatitis
  • Macerated or soggy
  • Erythema/ inflammation/ cellulitis
    Erythema (Red) Peri wound
  • Oedematous/ swelling
    Peri wound edema
  • Excoriated
    Excoriated skin Buttocks
  • Induration
  • Fibrotic / scarred
    Fibrotic / scarred
  • Hyperkeratotic
  • Callus


  • Exudate amount: Nil / Low; Small / Moderate; High; Large / Copious
  • Exudate type: Serous / clear (amber coloured); Haemoserous (pink), Purulent (thick, opaque, creamy)

Wound Edges

  • Epithelialisation (i.e. clearly defined attached edges)
  • Indistinct / Diffuse, Macerated (i.e. moist, wet, soggy)
  • Rolled edge
    Rolled wound edge
  • Raised edge
  • Tracking, tunnelling or sinus tract
    Example of sinus
  • Undermined unattached edges
    Courtesy of National Library of Medicine


  • Strong
  • Foul
  • Pungent
  • Faecal
  • Musty
  • Sweet

Wound Bed

  • Granulation (i.e. dark pink / red, clean)
  • Epithelialisation (i.e. pink, clean)
  • Slough (i.e. white, yellow, stringy tissue)
  • Necrotic / Eschar (i.e. black)
  • Hyper - granulation (i.e. dark pink, red, bumpy)

Temperature of surrounding skin

  • Normal
  • Warm
  • Hot
  • Cool


  • Location
  • Intensity (Pain score /10)