| Appearance | Color (pink, healing; yellow/green, infection; black, necrosis), sloughing, eschar, longitudinal streaking. |
| Size | Length, width, and depth in cm. |
| Incisions | Approximated edges, dehiscence, or evisceration. |
| Undermining | Use a sterile, cotton-tipped applicator to probe gently underneath edges until resistance is met; with a felttipped pen, mark where applicator can be felt under skin. |
| Induration | Abnormal firmness of tissues with margins. Assess by gently pinching tissue distal to wound edge; if indurated, you will be unable to pinch fold of skin. |
| Tissue Edema | Note whether edema is pitting or nonpitting. If wound is crepitant, notify physician immediately (may indicate gangrene). |
| Granulation | Bright red, shiny, and granular; an indication that wound is healing. Poorly vascularized tissue appears pale pink, dull, or dusky red. |
| Drainage | Type (sanguineous, serosanguineous, purulent), amount, color, and consistency. |
| Odor | Foul odor indicates infection. |
| Staging | See the section that immediately follows, Areas Susceptible to Pressure Injuries. |