SIGNTED ASSESSMENT

SIGNTED
Point Parameters Date/ Score

27/10 29/10 31/10 2/11 4/11 6/11

(1ST (2nd (3rd (4th (5th (6th
day) day) day) day) day) day)
S Size
0 Skin intact
1 Size less than 1 cm2
2 Size between 1 - 5 cm2
3 Size between 5 10 cm2
4 Size between 10 15 cm2
5 Size between 15 20 cm2 5
6 Size between 20 - 25 cm2 6 6 6 6 6
7 Size more than 25 cm2
I Inflammation/infection
0 None 0 0 0 0 0
1 Have some sign of inflammation (warm, swelling, pain, redness, 1
edema)
2 Have some sign of local infection ( warm, swelling, pain, redness,
edema, pus, induration, malodorous)
3 Have sign local infection, fever, osteomyelitis and or systemic
G Granulation tissue type
0 Granular and full granulation and or intact skin
1 Granular and granulation largely 1 1 1 1 1 1
2 Granular and granulation partially
3 Granular and granulation as small
 4 Granulation with problem: overgranulation and fragile and or non-
granular/flat
N Necrotic tissue type
0 None
1 Soft and have color one or more ( yellow, white, and gray) 1 1 1 1
2 Soft and have color one or more ( white, gray, brawn, black, yellow, 2 2
green)
3 Combination soft and hard with colors one or more (white, gray,
brawn, black, yellow, green)
4 Dry/wet necrotic tissue with 100% black color
T Tunneling/undermining
0 None 0 0 0 0 0
1 Less than 2 cm 1
2 Length 2 4 cm
3 Length > 4 cm
E Edge of wound (dominant type)
0 Wound edge pink, defined, attached and or intact skin
1 Wound edge have slightly one or more : hyperkeratosis, ring red,
rolled/lining, epibole, maseration in edge only, undefined, unattached,
purple
2 Wound edge have sign moderate one or more : hyperkeratosis, ring red,
rolled/lining, epibole, maceration around wound, undefined,
unattached, purple), purple
3 Wound edge have heavy one or more : hyperkeratosis, ring red, 3 3 3 3 3 3
rolled/lining, epibole, maceration beyond around wound, undefined,
unattached
D Depth
0 None
1 Depth included epidermis and dermis
2 Depth included subcutaneous and muscle
3 Depth until fascia, tendon and Bone 3 3 3 3 3 3
Total score 16 15 15 14 14 13
MUNGS ASSESSMENT
No Score Items Date
M Maceration
27/10 29/10 31/10 2/10 4/10 6/10
0 None
1 Thin at the edge an/ or maceration 2cm from the
wound edge
2 >2cm from the wound edge and/ or expended 2 2 2 2 2 2
U Undermining/ Tunnelling/ Sinus
0 None 0 0 0 0 0
1 3cm 1
2 3cm
N Necrotic Tissue Type (black, white, yellow, grey, brown,
green)
0 None
1 Soft slough and with 1 colour 1 1 1 1 1 1
2 Necrotic; with spongy, soft and coloured skin
3 Necrotic; hard, spongy or moist tissue and skin with
1 colour
4 Necrotic; dry, hard, black and/ or brownish
G Granulation Tissue
0 Skin intact
1 Full granulation (100%)
2 Granulation of 50% to <100% 2 2 2 2 2 2
3 Granulation of <50%
4 No Granulation
S Other Wound-Related Signs or Symptoms
Wound Edge: Around the Skin Wound: 0
Red ring ** Hyperpigmentation None
Hyperkeratoni Induration 1 1* 1* 1* 1* 1*
c Hypopigmentation One
Unattached* Erythema around the wound or
Undefined * Oedema Two
Crust Purple 2 2 */**
 Pale Lesion Three
Damage or
Epibole Granulation: Five
Rolled/ lining Fragile granulation 3
Bright red More
Wound Infection Hypergranulation Than
or Inflammation: Senescent Five
Pain Pale
Pus Blackish
Odour Trauma
Fever Tissue compatible with a biofilm
Rising
temperature/
warm
Total Score 8 6 6 6 6 6
 WOUND ASSESSMENT SCORE
18

16

14

12

10

0
1st day 2nd day 3rd day 4th day 5th day 6th day

SIGNTED MUNGS