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
