Pressure Ulcer Assessment- Top Ten To Dos from Skilled Wound Care
1. Always have good lighting during your pressure ulcer assessment preferably with a flashlight.
2. Have a reference card with pictures of various pressure ulcer stages, so that you can stage the wound correctly. If you need such a card, Skilled Wound Care has these available free of charge.
3. Get a second opinion from a knowledgeable colleague or a specialized wound care physician.
4. Always measure the wound starting with the length, then width, then depth. The convention is LXWXD in centimeters.
5. Make sure to differentiate between the wound, which is a break in the skin integrity versus the periwound (the area surrounding the wound).
6. If the wound is on a lower extremity, make sure to rule out vascular or diabetic disease as a cause.
7. Never downstage a wound hoping it will improve. Downstaging a wound is giving it a lower stage than it actually has.
8. When identifying a new pressure ulcer, make sure to discuss your findings with a supervisor.
9. Make sure to document your patient’s risk factors for the development of pressure ulcers.
10. Discuss your patient’s condition and wound with the patient and the family in an open, honest, and sincere fashion. It is better they find out from you then discover the wound on their own.
For more information on pressure ulcer assessment, education or to have a wound care physician visit your facility please call (310) 445-5999.