Staging Pressure Ulcers
Documentation of pressure ulcer treatment should include the stage of the pressure ulcer. Generally, there are four stages, each describing the severity of the wound. Pressure ulcers usually involve tissue damage which extends through the skin and into the underlying tissue. The most severe wounds extend into the bone and muscle.
Stage 1 pressure ulcers appear as a reddish area on the skin and typically have a different texture than the surrounding area. The area is usually itchy, slightly painful, and either warmer or cooler than the surrounding skin.
Stage 2 pressure ulcers cause partial skin damage which appears as a blister or abrasion. The ulcer is superficial with only a slight indentation in the skin.
Stage 3 pressure ulcers cause full skin damage and affects the underlying tissue. The wound is deep and severe.
Stage 4 pressure ulcers cause full skin damage, damage to underlying tissue, and damage to the underlying bone or muscle.
Determining the Size of Pressure Ulcers
Documentation of pressure ulcer treatment should include the size of the ulcer. Generally, the measurement is in centimeters and includes the length, width, and depth of the ulcer. The length is measured along the head to toe direction, while the width is measured along the hip to hip direction. The depth usually measures the deepest part of the visible wound bed.
Examining the Exudate
A description of the exudate should also be included in the documentation. Exudate is the fluid which is contained within the ulcer. The color, consistency, amount of fluid, and the presence or absence of odor is evaluated. Generally, there are five types of exudate. Sanguineous exudate consists of thin, bright red fluid, while serosanguineous exudate consists of watery, pale red to pink fluid. Serous exudate is clear and watery. Purulent exudate is thin to thick in consistency and tan to yellow in color. Foul purulent exudate is yellow to green, opaque, and foul smelling.
The wound can be completely filled with exudate, partially filled, or dry. Examining the dressing is the best way to determine the amount of exudate contained in the wound.
The treatment should be based on the severity of the pressure ulcer. The first step is usually to relieve the pressure on the wound. This usually involves the use of pillows, cushions, and sheepskin. Increasing movement and adjusting sitting or sleeping positions will also reduce the pressure on the wound. The number of times the patient is moved or placed in a new position should be documented.
The efforts taken to remove dead tissue from the wound site should also be documented. This may involve surgery. Afterwards, the steps taken to cover the wound, including the type of dressing and topical medications should be listed. The method to control infection and promote healing should also be recorded.