Clinicians may have difficulty in determining if a wound is truly a pressure ulcer. It is essential to not only assess the wound, but also perform a complete skin assessment and obtain a history.
To be determined a pressure ulcer, the wound needs to meet the criteria by the National Pressure Ulcer Advisory Panel, which is “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, or pressure in combination with shear.” Friction is no longer included in the definition of pressure ulcer.
After determining that the wound is a pressure ulcer, as opposed to a wound with another etiology based on information from the history and physical examination, skin assessment and, finally, the tissue involved in the wound bed, it is beneficial to identify the presence of significant risk factors for pressure ulcer development.
This is aided by determining the level of mobility of the resident, along with other comorbid diseases that influence general skin health. The resident’s perfusion and oxygenation levels and nutritional status are important to consider, as well as body temperature, sensory perception and general health condition.
Pressure ulcers are usually over a bony prominence. The anatomical position of a wound will guide you in determining if a wound is a pressure ulcer or a wound with another etiology.
When a wound is assessed as a pressure ulcer, pressure ulcer staging is initiated. Staging of a pressure ulcer is a method utilized by healthcare providers based on the amount of observable tissue loss, including the depth of the actual tissue loss. The National Pressure Ulcer Advisory Panel has specific criteria for each stage.