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pressure sore status tool (PSST); Bates-Jensen wound assessment tool

Indications: - validated instrument for evaluation & monitoring of pressure ulcer healing (wound healing)* * best instrument for monitoring the healing of pressure injuries [2] * contrast to pressure ulcer risk scales Norton scale & Braden scale used to assess risk of pressure ulcer [3] Method: 15 items: 2 non-scored items: 1) location of wound 2) shape of wound 13 scored items rated 1 (best) to 5 (worst) 1) size 2) depth 3) edges 4) undermining 5) necrotic tissue type 6) necrotic tissue amount 7) exudate type 8) exudate amount 9) skin color surrounding wound 10) peripheral tissue edema 11) peripheral tissue induration 12) granulation tissue 13) epithelialization Total score: (range: 13-65) - the pressure ulcer should be scored at baseline, then at regular intervals to assess healing

General

pressure ulcer assessment numerical rating scale (NRS)

References

  1. Bates-Jensen B. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  3. Bates-Jensen BM, McCreath HE, Harputlu D, et al. Reliability of the Bates-Jensen wound assessment tool for pressure injury assessment: the pressure ulcer detection study. Wound Repair Regen. 2019;27(4):386-395 PMID: 30828890 PMCID: PMC6693585 Free PMC article https://onlinelibrary.wiley.com/doi/10.1111/wrr.12714