HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 7-2
Skin Care: Pressure Ulcer - Assessment __RN
PURPOSE:
To provide recommendations for assessing the patient
and pressure ulcer.
CONSIDERATIONS:
1. Assessment is the starting point in preparing to treat
or manage an individual with a pressure ulcer.
2. Assessment involves the entire person, not just the
ulcer, and is the basis for planning treatment and
evaluating its effects.
3. Adequate assessment throughout the healing
process is critical to proper management and
healing.
4. Consulting an Enterostomal Therapist (ET) or
Certified Wound Care Nurse (CWCN) for Stages III,
IV and difficult to manage wound cases is
recommended.
5. Consults by nutritionist, physical therapist,
occupational therapist, and medical social worker
may also be required.
EQUIPMENT:
Gloves
Scale
Measuring guide
Sterile Q-tip (optional)
Camera, specific for wound measurement (optional)
PROCEDURE:
1. Adhere to Universal Precautions.
2. Explain procedure to patient.
3. After completing assessment discard soiled supplies
in appropriate containers.
Assessing the Ulcer
1. Initial assessment:
a. Position the patient exposing ulcer site.
b. Assess the pressure ulcer (s) for:
(1) Location
(2). Classification (When eschar or slough is
present, a pressure ulcer cannot be
accurately staged.)
(a) Stages:
Stage I: An observable pressure related
alteration of intact skin whose
indicators as compared to the adjacent
or opposite area on the body may
include changes in one or more of the
following: skin temperature (warmth or
coolness), tissue consistency (firm or
boggy feel) and /or sensation (pain,
itching). The ulcer appears as a
defined area of persistent redness in
lightly pigmented skin, whereas in
darker skin tones, the ulcer may
appear with persistent red, blue, or
purple hues.
Stage II: Partial thickness skin loss
involving epidermis, dermis, or both.
The ulcer is superficial and present as
an abrasion, blister or shallow crater.
Stage III: Full thickness skin loss involving
damage to or necrosis of
subcutaneous tissue that may extend
down to, but not through, underlying
fascia. The ulcer presents clinically as
a deep crater with or without
undermining adjacent tissue.
Stage IV: Full thickness skin loss with
extensive destruction, tissue necrosis,
or damage to muscle, bone, or
supporting structures (e.g., tendon or
joint capsule). Undermining and sinus
tracts may be associated with stage IV
pressure ulcers.
(b) Thickness:
Partial thickness: Extends through the first
layer of skin (epidermis) and into, but
not through, the second layer of skin
(dermis); heal by epithelialization.
Full thickness: Extends through both the
epidermis and dermis and may involve
subcutaneous tissue, muscle and,
possibly, bone.
(c) Color: The three-color concept is
designed for use with traumatic,
surgical, and other wounds that heal by
secondary intention.
Red: Indicates clean, healthy granulation
tissue.
Yellow: Indicates the presence of exudate
or slough produced by microorganisms
and the need for cleaning.
Black: Indicates the presence of eschar.
(3) Size:
(a) Length and width are measured as
linear distances from wound edge to
wound edge. Wound length is
measured from head to toe and width
is measured from side to side.
(b) Depth of a wound can be described as
the distance from the visible surface to
the deepest point in the wound. To
measure wound depth, gently insert a
sterile, flexible, (15 cm), cotton-tipped
applicator into the deepest part of the
wound. Then measure the length of
the cotton-tipped applicator that was in
the wound.
(4) Sinus tracts
(5) Undermining/tunneling (direction and depth
of tunneling). Document undermining/
tunneling using clock positions to describe
location.
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