Subjective
Date of visit
Reason for visit: Pressure ulcer evaluation and management
History of Present Illness
Date of pressure ulcer first noticed
Location of pressure ulcer (anatomical site)
Patient description of any pain, discomfort, or drainage
Activities of daily living (ADLs) and mobility (potential risk factors)
Continence status (bowel and bladder)
Recent changes in health status or medications
Past Medical History
Previous history of pressure ulcers
Conditions that may increase pressure ulcer risk (diabetes, vascular disease, malnutrition)
Surgeries (recent or relevant)
Social History
Nutritional status (diet, weight loss)
Smoking history (risk factor for delayed healing)
Living situation and support system
Objective
Vital signs (temperature, blood pressure, heart rate) – elevated temperature may suggest infection
Physical exam:
General assessment (skin integrity, signs of malnutrition)
Wound assessment using the PUSH tool (Pain, Undermining, Size, Healing tissue)
Pain: described by patient (location, intensity)
Undermining: presence of tunneling under the wound edges
Size: measured in centimeters (length, width, depth)
Healing tissue: presence of granulation tissue, signs of epithelialization
Stage of the pressure ulcer (using the National Pressure Injury Advisory Panel [NPIAP] staging system)
Diagnostic Tests (may be ordered depending on presentation):
Wound culture (to identify any bacterial infection)
X-ray or ultrasound (to assess for bone involvement in deeper ulcers)
Assessment
Stage of pressure ulcer (based on NPIAP staging)
Depth of tissue involvement
Presence of infection (based on clinical signs and possibly wound culture results)
Contributing factors to pressure ulcer development
Plan
Pressure ulcer staging and documentation using standardized terminology (NPIAP)
Wound care plan based on stage and assessment:
Pressure relief: essential for healing, using support surfaces (mattress, cushions) and frequent repositioning
Wound cleaning and dressing selection: appropriate cleaning solutions and dressings to promote healing
Pain management: medications and strategies to manage pain
Nutritional support: ensuring adequate protein and calorie intake for wound healing
Address any contributing factors (e.g., manage incontinence, improve mobility)
Referral to wound care specialist (if needed)
Education
Explain pressure ulcers, their causes, and stages.
Discuss the importance of pressure relief strategies (repositioning, support surfaces)
Provide education on skin care and hygiene to prevent further breakdown
Review the wound care plan and dressing changes (if applicable)
Importance of maintaining good nutrition for healing
Follow-up
Schedule for follow-up appointments:
Monitor wound healing progress
Adjust wound care plan as needed
Address any ongoing challenges or concerns
Additional Information
Document pressure ulcer location using a standardized body chart.
Include photographs of the pressure ulcer for serial monitoring.
Consider using a Braden Scale score to assess pressure ulcer risk.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pressure ulcers.