Proper documentation regarding the assessment of a pressure ulcer must

Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.)

1. Presence of pain
2. Depth of damage
3. Length and width
4. Presence of drainage
5. Description of drainage
6. Condition of surrounding tissue

ANSWER

ANS: 2, 3, 4, 5, 6
Assessment includes depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. Presence of pain is not a component of this charting.