The NICE guidance indicates that everyone with a pressure ulcer should receive an initial and ongoing holistic assessment. The
assessment should take account of the following factors:
- health status, eg acute chronic and terminal illness the potential impact of which on potential healing should be recorded. Co-morbidities such
as diabetes and malnutrion should also be taken into account;
- mobility status which should include all aspects of independent movement including walking, ability to reposisition - eg in a bed or a chair- and
transfer - for example from a bed to a chair;
- posture;
- the presence of sensory impairment in an individual with a pressure ulcer should be recorded;
- the level and duration of any impaired consciousness should be recorded;
- systemic signs of infection. The guidance says that "In the presence of systemic and clinical signs of infection in the patient with a pressure ulcer,
systemic anti-microbial therapy should be considered";
- putritional status;
- previous pressure damage should be recorded to include site/location, stage or grade of previous ulcer and previous interventions.
- pain status, a pain assessment should should include: whether the individual is experiencing pain; the causes of pain; level of pain (using
an appropriate tool); locations and management interventions;
- psychological status to include concordance and abilities of the individual to self-care;
- social factors to include the suitability of the home environment, level of supportive provision and the involvement of local support services;
- continence status to include whether the individual is continent of urine, faeces and continence interventions, which may affect ulcer healing and
impair the function of pressure relieving support surfaces- for example pads or bedding;
- medication;
- cognitive status;
- blood flow.
Ulcer Assessment
The NICE guidance states that patients with pressure ulcers should receive an initial and ongoing ulcer assessment. The aim of an ulcer assessment is to:
- establish the severity of the pressure ulcers
- generate a personal ulcer profile to develop a plan of care from which treatment interventions will be initiated.
- to evaluate treatment interventions.
- to assess for complications;
- to communicate information about the pressure ulcer to those involved in pressure ulcer management.
The guidance says that an ulcer assessment should include:
- cause of ulcer;
- site/location of ulcer;
- dimensions of ulcer;
- stage or grade;
- exudate amount and type;
- local signs of infection;
- pain;
- wound appearance;
- surrounding skin;
- undermining/tracking (sinus or fistula);
- odour
