PROFORMA Sheet no:

Patient Details: D.O.A:

Name: Diagnosis:

Age: Sex:

Present on Admission: Yes/ No

Risk of developing pressure ulcer:Yes/No

Measures taken to prevent Pressure Ulcer: Nimbus Mattress/Position Change

Pressure Ulcer Bundle Care followed daily : Yes/No

Site Grade

Stage –I : Inflammation or Reddening of the

skin

Stage-II : Superficial skin break with redness of

surrounding area

Stage-III : Skin break with deep tissue

involvement

Stage IV : Skin break with deep tissue

involvement with necrotic tissue present
Surgial opinion : Yes/No

Surgical Intervention : Yes/ No