Assessment of pressure ulcers

Various characteristics of a pressure ulcer are important, both in understanding the depth and degree of tissue damage and defining principles of care including dressing selection.

The following elements should be assessed:

  • Stage
  • Location
  • Size (length, width, depth)
    (photography may be prove useful)
  • Is undermining present?
  • Sinus tract/ tunneling
  • Necrotic tissue/slough presence
  • Granulation tissue presence
  • Exudate
  • Pain – Has pain assessment be conducted and pain relief strategies implemented
  • Peri wound skin condition