Assessing the pressure ulcer
Assessing the pressure ulcer
• Initial assessment. Assess the pressure ulcer(s) initially for location, stage, size (length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. (See sample pressure ulcer assessment guide.)
• Reassessment. Reassess pressure ulcers at least weekly. If the condition of the patient or wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted.
• Monitoring progress. A clean pressure ulcer should show evidence of some healing within two to four weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary.
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