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

A Pocket Guide for CliniciansMeasurement Parameter Clinical Observation IndicatorMeasureLength, width,depth, areaNursing Best Practice GuidelineAppendix J: MEASURE Assessment GuideSource: Sibbald, Orsted et al. (2006). Reprinted with permission.Reduction or increase in wound surface area and/or depthExudateAmount, quality■ Decreased or increased amount■ Decreased or increased purulenceAppearanceWound bed appearance,tissue type and amount■ Increased or decreased percentage of granulation tissue■ Increased or decreased percentage of necrotic tissue■ Friability of granulation tissueSufferingUnderminingPatient pain level usingvalidated pain scalePresence or absenceImproved or worsening wound-related painDecreased or increased amountRe-evaluateEdgeMonitor all parameterson regular basis – everyone to four weeksCondition ofwound edge andsurrounding skinParameters sequentially documented in patient record■ Presence or absence of attached edge with advancingborder of epithelium■ Presence or absence of erythema and/or induration■ Presence or absence of maceration91