Documentation of Ulcer

Information to be documented

 1. Date and time of assessment

 2. Type of wound and underlying etiology

 3. Factors that could delay wound healing

 4. Location of wound

 5. Duration of wound

 6. Wound measurements

 7. Depth of damage

 8. Type and color of tissue in wound bed

 9. Presence of infection

10. Exudate levels and type

11. Presence of odor

12. Presence of pain and its level

13. Wound margins

14. Dressing selection and regimen

Wound assessed at each dressing and measured at 4 weeks interval

Various parameters and techniques have been used to describe and document an ulcer on the lower extremities. Firstly, an ulcer anywhere in the body should be described under the following headings (Fig. 29.1).


Fig. 29.1
Chronic diabetic ulcers of the lower extremity


Document the location of the ulcer

For example, venous ulcers are more common in the gaiter area and pressure ulcer on pressure points like the sacrum, ischial tuberosity, and heel.



Document the type of wound according to etiology

For example, arterial, pressure ulcer, venous, diabetic, or neuropathic



Document the size

It is measured in cm in three dimensions:

  • Length (maximum measurement in a head to toe direction)

  • Width (maximum measurement at right angle to above)

  • Depth (deepest part of the visible wound bed is measured)



Document any sinus tract/undermining/tunneling

Undermining or tunneling is described as tissue destruction underneath the intact skin margins (Fig. 29.2). When this undermined area gets epithelialized, it forms a sinus tract.


Fig. 29.2
A diabetic foot ulcer with undermined edges



Document type/amount/odour of exudate:

  • Type – serous, serosanguinous, sanguinous, purulent

  • Amount none, scant, small, moderate, large

  • Odour absent or present



Describe the presence or absence of necrotic tissue

It could be slough or eschar (Fig. 29.3).


Fig. 29.3
Ulcer on plantar aspect of sole

Describe the amount and color. Describe whether it is nonadherent, loosely adherent, or firmly adherent.



Document about granulation tissue:

Whether it is pale or red, whether it is occupying whole of the floor or partial area of the ulcer floor, i.e., in islands or complete wound (Fig. 29.4).


Fig. 29.4
Chronic ulcer showing granulation tissue on its floor



Define the wound edges:

Defined or undefined. Whether macerated, fibrotic, or callused.



Describe the surrounding tissue:

Whether the surrounding skin is normal, hyperpigmented, have evidence of lipodermatosclerosis, or have prominent veins.


29.4 Classification of Ulcers

Various systems are available to describe the various types of ulceration.

29.4.1 Wagner System [6]

Has six grades from Grade 0 to Grade 5

  • Grade 0 – Pre- or post-ulcerative site

  • Grade 1 superficial ulcer

  • Grade 2 ulcer penetrating to the tendon or joint capsule

  • Grade 3 lesion involving deeper tissue

  • Grade 4 forefoot gangrene

  • Grade 5 whole-foot gangrene involving more than 2/3rd of the foot

Another system has been described by the University of Texas:

29.4.2 University of Texas System

Grade 0

Grade 1

Grade 2

Grade 3

Pre or post ulceration site

Superficial wound not involving the tendon, capsule, or bone or joint

Wound penetrating to the tendon or capsule

Ulcer penetrating to the bone or joint

Lesions without infection or ischemia

Infected/nonischemic lesions

Noninfection/ischemic lesions

Infected ischemic lesions

Another system is SAD System.

29.4.3 S(AD) SAD System (Area, Depth, Sepsis, Arteriopathy, and Denervation) [7]








Skin intact

Skin intact

Pedal pulses present



Lesion <1 cm2

Superficial (skin with SC tissue)

No infected lesions

Pedal pulses reduced or missing



Lesion from 1 to 3 cm2

Lesion penetrating to the tendon, periosteum, and joint capsules

Cellulite-associated lesion

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May 13, 2017 | Posted by in GENERAL SURGERY | Comments Off on Documentation of Ulcer

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