1 | 2 | 3 | 4 | 5 | |
---|---|---|---|---|---|
Elasticity | None | Poor | Fair | Good | Excellent |
Fluid volume (pooling of secretions) | None | Scant amount, vault not entirely covered | Superficial amount, vault entirely covered | Moderate amount of dryness (small areas of dryness on cotton-tip applicator) | Normal amount (fully saturates on cotton-tip applicator) |
pH | ≥6.1 | 5.6–6.0 | 5.1–5.5 | 4.7–5.0 | <4.6 |
Epithelial integrity | Petechiae noted before contact | Bleeds with light contact | Bleeds with scraping | Not friable, thin epithelium | Normal |
Moisture (coating) | None, surface inflamed | None, surface not inflamed | Minimal | Moderate | Normal |