Pressure ulcer assessment.
Pressure ulcer assessment requires quantification of multiple parameters of the ulcer and periulcer tissue. Clinical assessment should include ulcer history (including etiology, duration, and prior treatment), anatomic location, stage, size (including length, width, and depth measured in centimeters), sinus tracts, undermining, tunneling, exudate or drainage, necrotic tissue (slough and eschar), presence or absence of granulation tissue, and epithelialization. In addition, the ulcer borders can provide clues to healing potential. Intact skin surrounding the ulcer should be assessed for redness, warmth, induration or hardness, swelling, and any obvious signs of clinical infection. Pressure ulcer associated pain should be assessed prior to examination of the ulcer.
Maklebust
J
J
Harper Hospital, Detroit Medical Center, Detroit, Michigan 48201, USA.
D000886:Anthropometry / Q000379:methods; D019091:Critical Pathways; D006801:Humans; D008487:Medical History Taking / Q000379:methods*; D009730:Nursing Assessment; D010147:Pain Measurement; D010808:Physical Examination / Q000379:methods*; D003668:Pressure Ulcer / Q000145:classification / Q000209:etiology / Q000473:pathology*; D012307:Risk Factors; D012720:Severity of Illness Index; D014945:Wound Healing