Fig.

Pocket

Pigmentation
Necrotic tissue

Bleeding

Maceration
Blister

Granulation uneven

Hyperplasia

A. Wound Assessment
1. Causes: Pressure
 2. Location: (above a bony prominence)
3. DESIGN-R (D4 E6 s9 i0 G4 N3 P24) = 46
4. Size or Area
Wound 1 : 2.0 x 2.0 cm Pocket: 6.5 x 6.0 cm. Total of Size: 56.5 cm²
Wound 2 : 4.5 x 3.0 cm
5. Wound Bed
Red (Granulation: uneven), Yellow (Necrotic tissue)
6. Wound Edge
Distinct edges, Maceration, Hyperplasia, Blister, Bleeding
7. Skin Surrounding wound: Pigmentation
B. NPUAP Classification ;
Grade 4
C. Treatment
Debridement
Dressing
 Fibrinolysin, Bromelain, Sulfadiazine silver, fradiomycinsulfate , trypsin
 Intervention pocket uses syringe with catheter

Fig. 2
 Pocket

Necrotic tissue

Granulation
Blister

Maceration
Pigmentation

A. Wound Assessment
 1. Causes: Pressure
2. Location: (above a bony prominence)
3. DESIGN-R: D4 e3 s9 i0 g1 N3 P12= 28
4. Size or Area
Wound : 4.5 x 2.5 cm Pocket: 7.5 x 5.2 cm. Total of Size: 45.30 cm²
5. Wound Bed
Red (Granulation: uneven), Yellow (Necrotic tissue)
6. Wound Edge
Distinct edges, Maceration, Blister
7. Skin Surrounding wound: pigmentation
B. NPUAP Classification
Grade IV
C. Treatment
Debridement
Dressing: Hydrogel
Intervention pocket uses syringe with catheter
Fig. 3

Pocket
The remnants net of dressing
Necrotic tissue

Red ( Granulation) uneven

Maceration

Pigmentation

A. Wound Assessment
1. DESIGN-R; D4 e3 s9 i0 g1 N3 P24 = 40
2.
Size or Area ; Wound 4.5 x 3.5 cm Pocket; 6.5 x 6.5 cm. Total of size = 59 cm 2
3. Wound Bed ; Granulation (red) uneven, Necrotic tissue (Yellow)
4. Wound Edge ; Distinct edges, maceration, remnants net of dressing
5. Skin Surrounding wound; Pigmentation
B. NPUAP Classification
 Grade IV
C. Treatment
Debridement
Dressing: Hydrogel
Intervention pocket uses syringe with catheter
Fig. 4

Pocket
The remnant net of dressing
Necrotic Tissue

Red (Granulation)
Pigmentation
Maceratio
Yellow (Biofilm)
n
Yellow
A. Wound Assessment
1. DESIGN-R; D4 E6 s12 i0 g3 N3 P24=48
2. Size or Area
Wound 1: 1.6 x 1.5 cm Wound 2: 4.8 x 3.0 cm Pocket: 7.5 x 6.3 Total of size:65.05 cm 2
3. Wound Bed: Wet, Yellow (Biofilm), Red (Granulation)
4. Wound Edge: Maceration, wet
5. Skin Surrounding wound: Pigmentation
B. NPUAP Classification
Grade IV
C. Treatment
Debridement
Dressing: Sulfadiazine silver, Fibrinolysin, Bromelain
Pocket: Use cathater with syringe