pressure ulcer assessment

Procedure

• use pressure assessment tool (Bates-Jensen wound assessment tool)
• total patient assessment
  • pressure ulcer risk scale
  • history & physical examination
  • nutritional status
  • pain, provision of adequate analgesia
  • psychosocial health
• frequency & timing
  • initial assessment of admission to hospital or nursing home is not as reliable as 2nd assessment 24 hours later
  • acute care setting: on admission, 48 hours later, then QD
  • medical/surgical: on admission, 48 hours later, then QD
  • nursing home:
    • on admission, 48 hours later, then weekly for 4 weeks
    • after 4 weeks, on a routine basis, i.e. quarterly
  • home care:
    • on admission, 48 hours later, then on a routine basis, i.e. weekly

More general terms

• wound assessment

More specific terms

• pressure sore status tool (PSST); Bates-Jensen wound assessment tool
• pressure ulcer scale for healing (PUSH)

Additional terms

• pressure ulcer risk scale