RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Assessment & Management of Stage I to IV Pressure UlcersAppendix I – Wound Measurement, provides a diagram of the recommended technique for measuringpressure ulcer surface area and undermining. Combining multiple measurement techniques may help tomore accurately monitor and evaluate pressure ulcers. This clinical measurement can be achieved by usinga ruler (width/length/depth), other measurement devices, transparency tracings or photography(Consortium for Spinal Cord Medicine, 2000). Length is measured as the longest axis of the wound. Width ismeasured at 90 degrees to the length at the next longest axis. Lucas et al. (2002) combined full-scalephotography and transparency tracings for highly reliable measurement of stage III pressure ulcers.Sibbald, Orsted et al. (2006) suggest that the MEASURE mneumonic can be used to guide a consistentapproach to local wound assessment, though it is also emphasized that assessment must occur within thecontext of a global assessment of the particular client and environment. Refer to Appendix J for adescription of MEASURE.Numerous tools have been developed for documenting wound assessment. These assessment toolsinclude, but are not limited to: the Pressure Sore Status Tool (PSST); the National Pressure Ulcer AdvisoryPanel (NPUAP) Pressure Ulcer Scale for Healing (PUSH), the Wound Healing Scale (WHS), and the SussmanWound Healing Tool (SWHT). Appendix K – Documentation: Wound Assessment Tools provides examplesof tools for systematic assessment and documentation.In order to determine the adequacy of the treatment plan, it has been suggested that pressure ulcers bemonitored every time the dressing is changed and reassessed at least weekly (van Rijswijk & Braden, 1999). The panelfurther emphasizes that ongoing monitoring for emergent concerns and divergence from the assessment isessential for determining when a thorough re-assessment is warranted in advance of the weekly schedule.A clean pressure ulcer with adequate vascular supply receiving adequate treatment should show signs ofhealing within two to four weeks (AHCPR, 1994). If the condition of the patient or of the wound deteriorates,or if the goal of care is healing and no progress can be demonstrated, re-evaluate the treatment planand/or the presence of complications. Some wounds, however, will not heal. In this case, the goal ofhealing may be revised to prevent infection, to prevent further deterioration and to provide comfort, sothat quality of life and diginity is maintained.DebridementRecommendation 3.2aLower extremity ulcers or wounds in patients who are gravely palliative with dry eschar need not bedebrided if they do not have edema, erythema, fluctuance or drainage. Assess these wounds daily tomonitor for pressure ulcer complications that would require debridement.Level of Evidence – IVRecommendation 3.2bPrior to debridement on ulcers on the lower extremities, complete a vascular assessment (e.g.,clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toepressure) to rule out vascular compromise.Level of Evidence – IV34