HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 7-2
Skin Care: Pressure Ulcer - Assessment __RN
(6) Exudate/drainage (amount, color, and odor)
(7) Necrotic tissue (slough, eschar)
(8) Granulation/epithelialization
(9) Pain/tenderness
c. Assess the surrounding skin for:
(1) Erythema
(2) Maceration
(3) Induration
2. Reassessment:
a. Reassess pressure ulcers weekly, according to
the initial assessment guidelines.
b. It is not appropriate to reverse stage a pressure
wound. A stage 3 cannot become a stage 2 or
a stage 1. Chart the progress by noting an
improvement in the characteristics (size, depth,
etc.) or identify the wound as a healing stage 3
or a healed stage 3 wound.
c. Reevaluate the treatment plan as soon as any
evidence of deterioration is noted.
3. Monitoring progress:
a. A clean pressure ulcer with adequate
innervation and blood supply should show
evidence of some healing within two to four
weeks.
b. If progress is not demonstrated within four
weeks, reevaluate the overall treatment plan,
adherence to the treatment plan, and make
appropriate changes and referrals (ET, CWCN
etc).
Assessing the Individual
1. Physical health and complications.
a. Complete history and physical examination.
b. Complications (e.g., decreased mobility,
incontinence).
2. Nutritional assessment and management.
a. Adequate dietary intake, including calories,
protein, vitamins, and minerals.
b. Nutritional assessment.
(1) At least every three months for individuals
at risk for malnutrition.
(2) Laboratory tests, as ordered (e.g., albumin,
total protein, hematocrit).
(3) Height, weight, history of weight loss.
c. Nutritional support requirements (e.g., tube
feeding, nutritional supplements).
d. Vitamin and mineral supplement requirements
(e.g., vitamins A, C, Zinc).
e. Hydration status.
3. Pain assessment and management.
4. Psychosocial assessment and management.
a. Assessment of the individual to include:
(1) Mental status
(2) Learning abilities
(3) Signs of depression
(4) Social support
(5) Polypharmacy or over medication
(6) Alcohol or drug abuse
(7) Lifestyle
(8) Culture and ethnicity
(9) Stressors
b. Assessment of resources (e.g., availability and
skill of caregivers, finances, equipment).
c. Assessment of mechanical and environmental
factors.
AFTER CARE:
1. Document in patient’s record:
a. Findings from the assessment.
b. Instructions given to patient/caregiver for
establishing plan of care.
2. Discuss assessment with patient’s physician and
obtain orders for care.
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