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Word DOC  Pressure Ulcer Assessment Tool

A Pressure Ulcer A-S-S-E-S-S-M-E-N-T Tool
Elizabeth A. Ayello, PhD, RN, CWOCN

Although pressure ulcer staging systems are helpful in identifying a pressure ulcer's depth, they do not give information on other important characteristics of the wound.

The following toolbased on the mnemonic A-S-S-E-S-S-M-E-N-T was developed in a checklist format to provide a snapshot of the pressure ulcer's location, size, sinus tracts, tunneling, exudate, necrotic tissue, epithelialization, and presence or absence of granulation tissue.

It is not intended to measure healing but to provide data on wound status at a point in time. Additional findings that are not included on this tool, but should be documented in the patient's record, include physical and psychosocial health, complications of the pressure ulcer, and nutritional status.

Elizabeth A. Ayello, PhD, Rn, CWOCN, is Clinical Assistant Professor at New York University, New York, N.Y. Adapated from Nursing96 1996;26(10):62-3.

Client's Name _________________________________ Age _________
Date ________Time ____________ Number of pressure ulcers ________

A.  ANATOMIC LOCATION OF WOUND

  • Sacrum
  • Heel R L
  • Trochanter R L
  • Lateral malleolus R L
  • Ishcium R L
  • Elbow R L

AGE OF WOUND
_______ days or ________ months client has had the pressure ulcer

S. SIZE
_____ cm length _______ cm width _____ cm depth

SHAPE

  • Oval
  • Round
  • Other __________________

 STAGE

  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Unable to determine stage; ulcer is necrotic

S.  SINUS TRACT, TUNNELING, UNDERMINING

  • Sinus tract, tunneling (narrow tracts under the skin at ___________o'clock
  • Undermining (bigger area [than tunneling] of tissue destructionarea is more like a cave than a tract

E.  EXUDATE

Color

  • Serous
  • Serosanguineous
  • Sanguineous

Amount

  • Scant
  • Moderate
  • Large

Consistency

  • Clear
  • Purulent

S.  SEPSIS

  • Local infection
  • Systemic
  • None

S.  SURROUNDING SKIN

  • Dark
  • Discolored
  • Erythematous
  • Intact
  • Swollen
  • Other ____________________

M.  MARGINS

  • Attached (edges are connected to the sides of the wound)
  • Not attached (edges are not connected to the sides of the wound)
  • Rolled (edges appear rounded or rolled over)

 MACERATION

  • Present
  • Not Present

E.  ERYTHEMA

  • Present
  • Not Present

 EPITHELIAZATION

  • Present
  • Not Present

 ESCHAR (necrotic tissue)

  • Yellow slough
  • Black
  • Soft
  • Hard
  • Stringy

Area around eschar is:

  • Dry
  • Moist
  • Reddened

N.  NECROTIC TISSUE

  • Present
  • Not Present

 NOSE

  • Odor present
  • Odor not present

NEOVASCULARIZATION (blood vessels are visible)

  • Present
  • Not present

T.  TISSUE BED

  • Granulation tissue present
  • Not present

 TENDERNESS TO TOUCH

  • No pain
  • Pain present:
    • On touch
    • Anytime
    • Only when performing ulcer care

Patient getting pain medication

  • Yes
  • No

 TENSION

  • Tautness, hardness present
  • Not present

 TEMPERATURE

  • Skin warm to touch
  • Skin cool to touch
  • Normal

Source: Skin & Wound Care Website (link is no longer good, was) http://www.woundcarenet.com/advances/clinicalmgmt/wcf233.htm

 This might help you in looking up unfamiliar words: Medical Dictionary