The following provides a guideline for clinical assessment. Assessments are done at regular intervals and are used to drive treatment decisions.
- Assessment of risk or contributing factors: decreased sensory perception, moisture, immobility, poor nutrition, friction/shear. Tools like the Braden Scale are helpful in determining patient risk.
- Assessment of nutrition, pain, previous ulcer care (if applicable), level of understanding, compliance in care, and learning style.
- Assessment of wound: location, stage, infection, exudate, odor, size (length, width, and depth), necrotic tissue, granulation, epithelialization, undermining, and/or tunneling.
- Assessment of periwound skin: fragile, dry, macerated, indurated, erythematous.
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