pressure ulcer assessment

Procedure: 1) use pressure assessment tool (Bates-Jensen wound assessment tool) 2) total patient assessment a) pressure ulcer risk scale b) history & physical examination c) nutritional status d) pain, provision of adequate analgesia e) psychosocial health 3) frequency & timing a) initial assessment of admission to hospital or nursing home is not as reliable as 2nd assessment 24 hours later b) acute care setting: on admission, 48 hours later, then QD c) medical/surgical: on admission, 48 hours later, then QD d) nursing home: - on admission, 48 hours later, then weekly for 4 weeks - after 4 weeks, on a routine basis, i.e. quarterly e) home care: - on admission, 48 hours later, then on a routine basis, i.e. weekly

Specific

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

References

Bates-Jensen B. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001