Step 4: PU Assessment

Learn a reliable method for conducting a comprehensive wound assessment. The assessment guides intervention, provides a basis for comparison to evaluate healing, and helps predict time to healing.

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Purpose of a PU Evaluation

Let’s pick up where we left off in Step 3: What action is required if a nursing home resident is admitted with a pressure ulcer (PU) or, despite your best efforts, develops one? This section discusses procedures for completing an important assessment that is often left incomplete in nursing homes: PU evaluation.

Essentially a wound assessment, PU evaluation is recommended in all the best practice guidelines (see our related Links page) for several reasons. Data from this evaluation:
  • helps guide interventions
  • provides a basis for comparison to evaluate healing
  • helps predict time to healing
What the practice guidelines imply but stop short of spelling out is that if wound assessments are conducted at baseline and regular intervals thereafter, then there is an excellent chance that PU treatment and management will be carried out in an equally conscientious, clinically appropriate manner. The wound assessments, in other words, set the stage for—and inform—the procedures that follow.

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Incomplete Evaluations are Insufficient

A common problem in nursing homes is that facilities set this stage incompletely. At a minimum, nursing staff should assess an existing PU for four characteristics:
  • wound location
  • depth, or stage
  • size
  • necrotic tissue
In a recent evaluation study led by Dr. John F. Schnelle and his research team, we found that nursing home staff documented all four wound characteristics for just 38% of 120 residents with PUs (1). The two most commonly charted characteristics were wound location and stage, which is a measure of the wound’s depth. Both are important: Location can impact clinical interventions and stage is useful for diagnostic purposes. But even when considered together, these characteristics are insufficient to direct an effective treatment plan or achieve recommended evaluation goals; additional wound characteristics must also be assessed so that clinicians can evaluate and predict time to healing.

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Our Recommendation

The best way to ensure that you cover the necessary ground is to use a validated assessment tool that enables you to quickly assess wound status so that you can tell whether a PU is getting better or worse over time:
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The PUSH Tool 3.0

The National Pressure Ulcer Advisory Panel (NPUAP), the developer of PUSH, has this to say about use of its assessment tool:
“NPUAP recommends use of the PUSH Tool at ‘regular intervals.’ The AHCPR Treatment Guideline recommends assessments be performed ‘at least weekly’ and ‘if the condition of the patient or of the wound deteriorates.’ The PRESSURE ULCER HEALING CHART (which is attached to the PUSH Tool) will allow you to graph PUSH Tool scores over time for each ulcer. You should be able to ‘tell at a glance’ whether the ulcer is healing, remains unchanged, or is deteriorating… Any increase in the PUSH Tool score (indicating wound deterioration) requires a more complete assessment of the ulcer and the patient's overall condition (2).”

The PUSH Tool, which monitors a wound’s length and width, exudate amount, and tissue type, is best used as a method for predicting wound healing. Notes the NPUAP, “In developing specific treatment plans, you will need to assess additional (wound) parameters (2).”

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In-Service Training Recommended

Regardless of which assessment tool your facility adopts, you should offer in-service education to make sure licensed nursing staff responsible for administering the tool know how to use the tool correctly. It helps to demonstrate proper use with actual residents. It’s also a good idea to arrange for experienced users and new users to assess a few of the same residents on the same day so that they can compare results. If wide or consistent scoring discrepancies occur, both users should discuss their results in the context of the tool’s scoring instructions and try to reach consensus for conducting subsequent assessments.

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Pressure Ulcer Treatment

As noted at the start of this section, wound assessment sets the stage for PU treatment. A detailed discussion of recommended treatment strategies is beyond the scope of this training module. Besides, it’s not needed: A number of clinical practice guidelines already cover that territory. We recommend that you check them out. They’re listed on the links page:

Visit the National Pressure Ulcer Advisory Panel website for additional information and education on PU treatment. Also, check out these pages on this website:
As always, feel free to contact us if you have unanswered questions or need other information.

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