Geriatric Quick Consult      Pressure Ulcers      Do #3

Do a complete initial wound assessment.

Knowledge Action

The wound should be assessed for location, stage, presence of tunneling or sinus tracts, undermining, exudates, necrotic tissue, evidence of healing (granulation tissue and epithelialization).

Refer to the standard staging systems1.
Click here to see pressure ulcer staging.

Necrotic tissue must be removed to determine the stage.

  • Assess wound


  • Follow standard staging


  • Remove necrotic tissue.
An exception to the need to remove eschar is a heel with dry adherent eschar.

If there are no signs of inflammation (erythema, drainage, softening of surrounding tissue), eschar can probably be left in place, and the wound observed closely for any change.

This is especially true in patients with poor arterial circulation who may not heal the open wound.
  • Leave eschar on heel if dry, adherent eschar.


  • Observe wound closely.
The length, width, and depth of the ulcer should be measured and documented.

The degree of undermining and tunneling should be documented also.

Reassess wounds whenever the condition of the patient deteriorates, or if there is increased exudate, edema, pain, or evidence of systemic infection.

Osteomyelitis usually takes weeks or months to develop and is found with large/deep wounds.

Doing X-rays for all wounds is an unnecessary expense1.
  • Measure and document length, width, and depth of ulcer.


  • Document degree of undermining and tunneling.


  • Reassess wounds if draining a lot or patient is "sick" (fever etc.).


  • Use X-rays selectively.

References:

  1. Bergstrom, N, Bennett MA, Carlson CE, et al. Clinical Practice guideline number 15: Treatment of pressure ulcers.
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