How to Perform Health Assessment of a Pressure Ulcer

Pressure ulcers occur due to prolonged, unrelieved pressure on the skin. They are also referred to as bed sores, pressure sores or decubitus ulcers. Pressure ulcers are wounds that appear in particular areas of the skin that have been subjected to pressure. Some causes of this condition are impaired mobility, lack of sensation in certain areas of the body, friction and shear. Nurses perform assessments of pressure ulcers to determine if they are healing appropriately or if additional treatments are needed. This is important to prevent skin deterioration or infection and to enhance wound healing.

Things You'll Need

• Gloves
• Disposable Rulers
• Cotton Tipped Applicators

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Instructions

• 1

  Take note of the number of pressure ulcers on your client's skin. Each one should be assessed separately. Wash your hands and put on clean gloves to avoid contaminating the wound with disease-causing organisms.

• 2

  Observe the pressure ulcer for the type of tissue present in it. Inspect the color and percentage of tissue in the wound. Do this to determine if the wound is healing properly or not. Red granular tissue indicates that the wound is healing well. This also determines the type of dressing that you will put over the wound.

• 3

  Measure the size of the wound with a disposable ruler. Measure the wound from left to right and from top to bottom. This tells you if the wound is healing properly or if it is getting bigger and not healing as desired.

• 4

  Determine how deep the wound is. Place a cotton-tipped applicator in the deepest part of the wound. Take note of the area on the cotton-tipped applicator that corresponds to the depth of the wound. Take out the applicator, place it next to a ruler and write down how deep the wound is based on the value on the ruler.

• 5

  Check the wound for undermining. This is a condition where there is no tissue under parts of the skin. When you place a cotton-tipped applicator under skin that has undermining, it goes in without any obstruction. Measure the depth of undermining by placing a cotton-tipped applicator under the skin around the pressure ulcer. Measure the length that goes into the skin using a ruler. Place the cotton-tipped applicator next to a ruler after taking note of how far the applicator went into the skin. This measurement tells you if tissue has been lost from the wound.

• 6

  Observe for drainage, odor, redness, warmth, pain and tenderness in and around the wound. This gives you information as to whether the wound you are assessing is infected or not. Presence of some or all of these factors may mean that the wound is infected. Look at the periwound skin-- edges of the wound-- as well. Breakdown in this area may also be an indication of a wound infection.

• 7

  Take off your gloves, wash your hands and document your findings.