Skip to main content
SpringerLink
Log in

Assessment and Documentation of Pressure Ulcers

  • Chapter
  • First Online:
Book cover Pressure Ulcers in the Aging Population

Part of the book series: Aging Medicine ((AGME,volume 1))

Abstract

Pressure ulcer assessment includes the correct diagnosis, classification, and wound assessment. Pressure ulcers are caused by compression of skin and/or subcutaneous fat and/or muscle tissue between hard internal body structures and hard external devices or support surfaces. Pressure ulcers are classified according to their depth and kinds of involved tissues. Differentiating pressure ulcer from other skin or tissue lesions is difficult and accurate classification is challenging. Pressure ulcer wound assessments further include the determination of location, size, tissue types and their quality, possible undermining, kind and amount of exudates, odor, edge, periwound appearance, and pain. Standardized tools and scores are available for wound assessment and/or predicting of healing.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 64.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 84.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer prevention and treatment. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

    Google Scholar 

  2. Takahashi M, Black J, Dealey C, Gefen A. Pressure in context. Pressure, shear, friction and microclimate in context A consensus document. London: Wounds International; 2010.

    Google Scholar 

  3. Lindgren M, Unosson M, Fredrikson M, Ek AC. Immobility–a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study. Scand J Caring Sci. 2004;18(1):57–64. Epub 2004/03/10.

    Article  PubMed  Google Scholar 

  4. Nonnemacher M, Stausberg J, Bartoszek G, Lottko B, Neuhaeuser M, Maier I. Predicting pressure ulcer risk: a multifactorial approach to assess risk factors in a large university hospital population. J Clin Nurs. 2009;18(1):99–107. Epub 2009/01/06.

    Article  PubMed  Google Scholar 

  5. Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA. 1995;273(11):865–70. Epub 1995/03/15.

    Article  CAS  PubMed  Google Scholar 

  6. Berlowitz DR, Brandeis GH, Morris JN, Ash AS, Anderson JJ, Kader B, et al. Deriving a risk-adjustment model for pressure ulcer development using the minimum data set. J Am Geriatr Soc. 2001;49(7):866–71. Epub 2001/08/31.

    Article  CAS  PubMed  Google Scholar 

  7. Vandenkerkhof EG, Friedberg E, Harrison MB. Prevalence and risk of pressure ulcers in acute care following implementation of practice guidelines: annual pressure ulcer prevalence census 1994–2008. J Healthc Qual. 2011. doi: 10.1111/j.1945-1474.2010.00127.x. Epub 2011/11/09.

  8. VanGilder C, MacFarlane G, Meyer S, Lachenbruch C. Body mass index, weight, and pressure ulcer prevalence: an analysis of the 2006–2007 International Pressure Ulcer Prevalence Surveys. J Nurs Care Qual. 2009;24(2):127–35. Epub 2009/03/17.

    Article  PubMed  Google Scholar 

  9. Vanderwee K, Defloor T, Beeckman D, Demarre L, Verhaeghe S, Van Durme T, et al. Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey. BMJ Qual Saf. 2011;20(3):260–7. Epub 2011/01/07.

    Article  PubMed  Google Scholar 

  10. Jaul E. A prospective pilot study of atypical pressure ulcer presentation in a skilled geriatric nursing unit. Ostomy Wound Manage. 2011;57(2):49–54. Epub 2011/02/26.

    PubMed  Google Scholar 

  11. Skillman J, Thomas S. An audit of pressure sores caused by intermittent compression devices used to prevent venous thromboembolism. J Perioper Pract. 2011;21(12):418–20. Epub 2012/01/24.

    PubMed  Google Scholar 

  12. Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res. 1975;112:89–100. Epub 1975/10/01.

    PubMed  Google Scholar 

  13. Reid J, Morison M. Classification of pressure sore severity. Nurs Times. 1994;90(20):46–50. Epub 1994/05/18.

    CAS  PubMed  Google Scholar 

  14. Kottner J, Raeder K, Halfens R, Dassen T. A systematic review of interrater reliability of pressure ulcer classification systems. J Clin Nurs. 2009;18(3):315–36. Epub 2009/02/05.

    Article  PubMed  Google Scholar 

  15. WHO. ICD-10 Version. 2010. http://apps.who.int/classifications/icd10/browse/2010/en

  16. Fromy B, Abraham P, Saumet JL. Non-nociceptive capsaicin-sensitive nerve terminal stimulation allows for an original vasodilatory reflex in the human skin. Brain Res. 1998;811(1–2):166–8. Epub 1998/11/07.

    Article  CAS  PubMed  Google Scholar 

  17. Kallman U, Bergstrand S, Ek AC, Engstrom M, Lindberg LG, Lindgren M. Different lying positions and their effects on tissue blood flow and skin temperature in older adult patients. J Adv Nurs. 2012;69(1):133–44. Epub 2012/04/11.

    Article  PubMed  Google Scholar 

  18. Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. J Am Acad Dermatol. 1982;6(6):1014–21. Epub 1982/06/01.

    Article  CAS  PubMed  Google Scholar 

  19. Dealey C, Lindholm C. Pressure ulcer classification. In: Romanelli M, editor. Science and practice of pressure ulcer management. London: Springer; 2006.

    Google Scholar 

  20. Inui S, Ikegawa H, Itami S. Dermoscopic evaluation of erythema associated with pressure ulcers. Int J Dermatol. 2011;50(8):945–7. Epub 2011/07/26.

    Article  PubMed  Google Scholar 

  21. Nixon J, Cranny G, Bond S. Skin alterations of intact skin and risk factors associated with pressure ulcer development in surgical patients: a cohort study. Int J Nurs Stud. 2007;44(5):655–63. Epub 2006/04/25.

    Article  PubMed  Google Scholar 

  22. Vanderwee K, Grypdonck M, Defloor T. Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial. J Clin Nurs. 2007;16(2):325–35. Epub 2007/01/24.

    Article  PubMed  Google Scholar 

  23. Fromy B, Sigaudo-Roussel D, Gaubert-Dahan ML, Rousseau P, Abraham P, Benzoni D, et al. Aging-associated sensory neuropathy alters pressure-induced vasodilation in humans. J Invest Dermatol. 2010;130(3):849–55. Epub 2009/09/04.

    Article  CAS  PubMed  Google Scholar 

  24. Vanderwee K, Grypdonck MH, De Bacquer D, Defloor T. The reliability of two observation methods of nonblanchable erythema, Grade 1 pressure ulcer. Appl Nurs Res. 2006;19(3):156–62. Epub 2006/08/01.

    Article  PubMed  Google Scholar 

  25. Kottner J, Dassen T, Lahmann N. Comparison of two skin examination methods for grade 1 pressure ulcers. J Clin Nurs. 2009;18(17):2464–9. Epub 2009/08/22.

    Article  PubMed  Google Scholar 

  26. Sterner E, Lindholm C, Berg E, Stark A, Fossum B. Category I pressure ulcers: how reliable is clinical assessment? Orthop Nurs. 2011;30(3):194–205. quiz 6–7. Epub 2011/05/21.

    Article  CAS  PubMed  Google Scholar 

  27. Bruce TA, Shever LL, Tschannen D, Gombert J. Reliability of pressure ulcer staging: a review of literature and 1 institution's strategy. Crit Care Nurs Q. 2012;35(1):85–101. Epub 2011/12/14.

    Article  PubMed  Google Scholar 

  28. Kottner J, Balzer K, Dassen T, Heinze S. Pressure ulcers: a critical review of definitions and classifications. Ostomy Wound Manage. 2009;55(9):22–9. Epub 2009/10/03.

    PubMed  Google Scholar 

  29. Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: superficial skin changes and deep pressure ulcer framework(c). Adv Skin Wound Care. 2011;24(12):571–80. quiz 81–2. Epub 2011/11/22.

    Article  PubMed  Google Scholar 

  30. Langemo D, Hanson D, Hunter S, Thompson P, Oh IE. Incontinence and incontinence-associated dermatitis. Adv Skin Wound Care. 2011;24(3):126–40. quiz 41–2. Epub 2011/02/18.

    Article  PubMed  Google Scholar 

  31. Gray M, Beeckman D, Bliss DZ, Fader M, Logan S, Junkin J, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;39(1):61–74. Epub 2011/12/24.

    Article  PubMed  Google Scholar 

  32. Defloor T, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Lubbers M, et al. Statement of the European Pressure Ulcer Advisory Panel–pressure ulcer classification: differentiation between pressure ulcers and moisture lesions. J Wound Ostomy Continence Nurs. 2005;32(5):302–6. discussion 6. Epub 2005/10/20.

    Article  PubMed  Google Scholar 

  33. Zulkowski K. Perineal dermatitis versus pressure ulcer: distinguishing characteristics. Adv Skin Wound Care. 2008;21(8):382–8. quiz 9–90. Epub 2008/08/06.

    Article  PubMed  Google Scholar 

  34. Australian Wound Management Association. Pan Pacific clinical practice guideline for the prevention and management of pressure injury. Osborne Park: Cambridge Media; 2012.

    Google Scholar 

  35. Ankrom MA, Bennett RG, Sprigle S, Langemo D, Black JM, Berlowitz DR, et al. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Adv Skin Wound Care. 2005;18(1):35–42. Epub 2005/02/17.

    Article  PubMed  Google Scholar 

  36. Groth K-E. Klinische Beobachtungen und experimentelle Studien über die Entstehung des Decubitus. Acta Chir Scand. 1942;87 Suppl 76:198–200.

    Google Scholar 

  37. Aoi N, Yoshimura K, Kadono T, Nakagami G, Iizuka S, Higashino T, et al. Ultrasound assessment of deep tissue injury in pressure ulcers: possible prediction of pressure ulcer progression. Plast Reconstr Surg. 2009;124:540–50. Epub 2009/08/01.

    Article  CAS  PubMed  Google Scholar 

  38. VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006–2009. Adv Skin Wound Care. 2010;23(6):254–61. Epub 2010/05/22.

    Article  PubMed  Google Scholar 

  39. Young DL, Estocado N, Landers MR, Black J. A pilot study providing evidence for the validity of a new tool to improve assignment of national pressure ulcer advisory panel stage to pressure ulcers. Adv Skin Wound Care. 2011;24(4):168–75. Epub 2011/03/23.

    Article  PubMed  Google Scholar 

  40. Yabunaka K, Iizaka S, Nakagami G, Aoi N, Kadono T, Koyanagi H, et al. Can ultrasonographic evaluation of subcutaneous fat predict pressure ulceration? J Wound care. 2009;18(5):192, 4, 6. passim. Epub 2009/05/15.

    Google Scholar 

  41. Kottner J, Dassen T, Lahmann N. Prevalence of deep tissue injuries in hospitals and nursing homes: two cross-sectional studies. Int J Nurs Stud. 2010;47(6):665–70. Epub 2009/12/08.

    Article  PubMed  Google Scholar 

  42. Berlowitz DR, Brienza DM. Are all pressure ulcers the result of deep tissue injury? A review of the literature. Ostomy Wound Manage. 2007;53(10):34–8. Epub 2007/11/06.

    PubMed  Google Scholar 

  43. Lahmann NA, Kottner J. Relation between pressure, friction and pressure ulcer categories: a secondary data analysis of hospital patients using CHAID methods. Int J Nurs Stud. 2011;48(12):1487–94. Epub 2011/08/16.

    Article  PubMed  Google Scholar 

  44. Kottner J, Gefen A. Incidence of pressure ulcers as primary outcomes in clinical trials: a comment on McInnes et al. (2012). Int J Nurs Stud. 2012;49(3):372–4.

    Article  PubMed  Google Scholar 

  45. Beeckman D, Schoonhoven L, Fletcher J, Furtado K, Gunningberg L, Heyman H, et al. EPUAP classification system for pressure ulcers: European reliability study. J Adv Nurs. 2007;60(6):682–91. Epub 2007/11/28.

    Article  PubMed  Google Scholar 

  46. Beeckman D, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Paquay L, et al. Pressure ulcers and incontinence-associated dermatitis: effectiveness of the pressure ulcer classification education tool on classification by nurses. Qual Saf Health Care. 2010;19(5):e3. Epub 2010/07/31.

    Article  PubMed  Google Scholar 

  47. Mastronicola D, Romanelli M. Clinical and instrumental assessment of pressure ulcers. In: Romanelli M, editor. Science and practice of pressure ulcer management. London: Springer; 2006.

    Google Scholar 

  48. Weir D. Pressure ulcers: assessment, classification, and management. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malver, PA: HMP Communications; 2007.

    Google Scholar 

  49. Hermanns JF, Petit L, Hermanns-Le T, Pierard GE. Analytic quantification of phototype-related regional skin complexion. Skin Res Technol. 2001;7(3):168–71. Epub 2001/09/14.

    Article  CAS  PubMed  Google Scholar 

  50. Rijswijk LV, Catanzaro J. Wound assessment and documentation. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. HMP Communications: Malver, PA; 2007.

    Google Scholar 

  51. Panfil EM, Linde E. Valid and reliable methods for describing pressure sores and leg ulcer–a systematic literature review. Pflege. 2007;20(4):225–47. Epub 2007/11/21.

    Article  PubMed  Google Scholar 

  52. Ahn C, Salcido RS. Advances in wound photography and assessment methods. Adv Skin Wound Care. 2008;21(2):85–93. quiz 4–5. Epub 2008/03/20.

    Article  PubMed  Google Scholar 

  53. Sprigle S, Nemeth M, Gajjala A. Iterative design and testing of a hand-held, non-contact wound measurement device. J Tissue Viability. 2012;21(1):17–26. Epub 2011/09/29.

    Article  PubMed  Google Scholar 

  54. Bradshaw LM, Gergar ME, Holko GA. Collaboration in wound photography competency development: a unique approach. Adv Skin Wound Care. 2011;24(2):85–92. quiz 3–4. Epub 2011/01/12.

    Article  PubMed  Google Scholar 

  55. Black J, Baharestani M, Black S, Cavazos J, Conner-Kerr T, Edsberg L, et al. An overview of tissue types in pressure ulcers: a consensus panel recommendation. Ostomy Wound Manage. 2010;56:28–44. Epub 2010/04/29.

    PubMed  Google Scholar 

  56. Ohura T, Ohura N. Pathogenetic mechanisms and classification of undermining in pressure ulcers—elucidation of relationship with deep tissue injuries. Wounds. 2006;18(12):329–39.

    Google Scholar 

  57. Stotts N. Assessing a patient with a pressure ulcer. In: Morison MJ, editor. The prevention and treatment of pressure ulcers. London: Mosby; 2001.

    Google Scholar 

  58. Ueta M, Sugama J, Konya C, Matsuo J, Matsumoto M, Yabunaka K, et al. Use of ultrasound in assessment of necrotic tissue in pressure ulcers with adjacent undermining. J Wound Care. 2011;20(11):503–4, 6, 8. passim. Epub 2012/01/14.

    CAS  PubMed  Google Scholar 

  59. National Pressure Ulcer Advisory Panel. Pressure Ulcer Scale for Healing (PUSH) PUSH Tool 3.0. National Pressure Ulcer Advisory Panel. 1998 [cited 2012]. http://www.npuap.org/PDF/push3.pdf

  60. Bates-Jensen B. The pressure sore status tool: an outcome measure for pressure sores. Top Geriatr Rehabil. 1994;9(4):17–34.

    Article  Google Scholar 

  61. Sanada H, Iizaka S, Matsui Y, Furue M, Tachibana T, Nakayama T, et al. Clinical wound assessment using DESIGN-R total score can predict pressure ulcer healing: pooled analysis from two multicenter cohort studies. Wound Repair Regen. 2011;19(5):559–67. Epub 2011/11/19.

    Article  PubMed  Google Scholar 

  62. Sussman C, Bates-Jensen B. Wound care: a collaborative practice manual: a collaborative practice manual for health professionals. Philadelphia, PA: Lippincott William & Wilkins; 2007.

    Google Scholar 

  63. Deutsches Netztwerk für Qualitätsentwicklung in der Pflege. [Expert Standard for People with Chronic Wounds]. Osnabrück, Germany2009.

    Google Scholar 

  64. Deutsche Gesellschaft für Wundheilung. Lokaltherapie chronischer Wunden bei Patienten mit den Risiken periphere arterielle Verschlusskrankheit, Diabetes mellitus, chronische venöse Insuffizienz 2012. http://www.awmf.org/uploads/tx_szleitlinien/091-001l_S3_Lokaltherapie_chronischer_Wunden_2012-06.pdf

  65. Menke NB, Ward KR, Witten TM, Bonchev DG, Diegelmann RF. Impaired wound healing. Clin Dermatol. 2007;25(1):19–25. Epub 2007/02/06.

    Article  PubMed  Google Scholar 

  66. Wyffels JT, Edsberg LE. Granulation tissue of chronic pressure ulcers as a predictive indicator of wound closure. Adv Skin Wound Care. 2011;24(10):464–73. Epub 2011/09/20.

    Article  PubMed  Google Scholar 

  67. Ranzer MJ, DiPietro LA. Impaired wound repair and delayed angiogenesis. In: Farage MA, Miller KW, Maibach HI, editors. Textbook of aging skin. Berlin: Springer; 2010. p. 897–906.

    Chapter  Google Scholar 

  68. Weier D. Pressure ulcers: assessment, classification, and management. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malver, PA: HMP Communications; 2007.

    Google Scholar 

  69. Thomas DR, Rodeheaver GT, Bartolucci AA, Franz RA, Sussman C, Ferrell BA, et al. Pressure ulcer scale for healing: derivation and validation of the PUSH tool. The PUSH Task Force. Adv Wound Care. 1997;10(5):96–101. Epub 1997/11/18.

    CAS  PubMed  Google Scholar 

  70. George-Saintilus E, Tommasulo B, Cal CE, Hussain R, Mathew N, Dlugacz Y, et al. Pressure ulcer PUSH score and traditional nursing assessment in nursing home residents: do they correlate? J Am Med Dir Assoc. 2009;10(2):141–4. Epub 2009/02/04.

    Article  PubMed  Google Scholar 

  71. Falanga V, Saap LJ, Ozonoff A. Wound bed score and its correlation with healing of chronic wounds. Dermatol Ther. 2006;19(6):383–90. Epub 2007/01/04.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany

    Jan Kottner

  2. Department of Nursing Science, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany

    Kathrin Raeder

Authors
  1. Jan Kottner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kathrin Raeder
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jan Kottner .

Editor information

Editors and Affiliations

  1. Division of Geriatric Medicine, Saint Louis University, Saint Louis, Missouri, USA

    David R. Thomas, MD

  2. Geriatric Medicine and Palliative Care, Wound Care Consultant, Hospice Care of South Carolina, Johns Island, South Carolina, USA

    Gregory A. Compton, MD

Rights and permissions

Reprints and permissions

Copyright information

© 2014 Springer Science+Business Media New York

About this chapter

Cite this chapter

Kottner, J., Raeder, K. (2014). Assessment and Documentation of Pressure Ulcers. In: Thomas, MD, D., Compton, MD, G. (eds) Pressure Ulcers in the Aging Population. Aging Medicine, vol 1. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-62703-700-6_4

Download citation

  • DOI: https://doi.org/10.1007/978-1-62703-700-6_4

  • Published:

  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-62703-699-3

  • Online ISBN: 978-1-62703-700-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation