Pressure ulcer evaluation: Best practice for clinicians
The Wound, Ostomy and Continence Nurses (WOCN) Society recognizes and supports the fact that a pressure ulcer evaluation represents one aspect of a comprehensive patient assessment which includes, but may not be limited to: history and physical examination, risk factors for pressure ulcer development, comorbidities, individual goals, and expectations.
What is a pressure ulcer?
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers.
Why is the pressure ulcer evaluation significant?
Accurate pressure ulcer evaluation and documentation is key to providing appropriate, individualized wound care; determining the effectiveness of care provided; modifying the plan of care as needed; obtaining reimbursement; and preventing litigation.
Are there standard procedures for evaluating pressure ulcers?
The WOCN Society recently identified best practices for clinicians to guide pressure ulcer evaluations. These practices provide evidence-based guidelines for the evaluation and documentation of pressure ulcers in a variety of care settings and can be used by all levels of healthcare practitioners. Pressure ulcer evaluation may vary depending on the care setting, institutional guidelines, skill of the caregiver, and overall goals for the individual patient. In developing pressure ulcer policies, procedures, and programs, use of the following are essential:
Location: Use anatomical terms and indicate whether the pressure ulcer is located to the right of or to the left of. Anatomical drawings may be helpful.
Shape: Document the shape (e.g., round, oval). Consider photographing and tracing shapes.
Size: Record as length by width by depth in centimeters.
Stage: Pressure ulcer stage should be identified using the National Pressure Ulcer Advisory Panel guidelines.
Tissue Type in the Wound Bed: Document the presence, amount, and location of the tissue type, as well as any foreign bodies.
Wound Edges: Observe for and document any distinct edges.
Margins: Observe for and document the presence of sinus tracts, tunneling, and undermining.
Periwound Skin: This should be intact. Observe and document if suspicious color, temperature, turgor, moisture-associated skin damage, maceration, callus, tenderness/pain, induration, edema, fluctuance, absence of hair, skin denudation/erosion, or presence of staples or sutures are found within 4 cm of the wound edges.
Exudate: Describe the type that is present in the wound. Address color, amount, and odor.
Wound Pain: Observe for and document intensity, location, quality, onset, duration, aggravating factors, effects, spontaneous pain, induced pain, positional pain, and goals of pain management.
Infection: Observe for and document signs of acute/classic and chronic infections.
Wound Age: Acute and chronic wounds heal differently. Clinicians must be aware of the differences to address the characteristics of delayed healing.
Frequency of Wound Evaluation: Minimally, wounds should be evaluated on admission, weekly, and with any signs of deterioration. Frequency is also determined by overall patient condition, wound severity, patient environment goals, and plan of care.
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