II. Indications

  1. Patients at high risk of Pressure Injury (e.g. Decubitus Ulcer)
    1. See Pressure Injury

III. Timing

  1. Perform baseline exam on inpatient or Skilled Nursing Facility Admission
  2. Perform at periodic intervals, adjusted for acuity of illness and clinical status changes

IV. Exam: General

  1. Perform full skin exam, uncovering all surfaces for examination
  2. Focus on bony prominence regions and areas of medical device contact (see Decubitus Ulcer)
  3. Evaluate skin integrity
    1. Erythema (blanchable or nonblanchable?)
    2. Skin firmness
    3. Moisture
    4. Pain or tenderness
    5. Temperature variation

V. Exam: Pressure Injury Characterization

  1. See Pressure Injury
  2. See Comprehensive Skin Integrity Assessment
  3. Document each region of Pressure Injury (with images taken for the EHR)
  4. Basic description
    1. Include images and diagrams in EHR
    2. Location
    3. Size (Length x Width x Depth)
    4. Timing (onset and progression)
  5. Stage (Types 1-4)
    1. See Decubitus Ulcer Grade
    2. Staging precautions
      1. Accurate grading requires Debridement of necrosis first
      2. Use other grading schemes for staging of Diabetic Foot Ulcers and Venous Stasis Ulcers
      3. Macerated skin (moisture induced wounds) are not staged
    3. Stage 1: Nonblanchable erythema of intact skin (pink skin, not purple)
    4. Stage 2: Superficial or partial thickness skin loss (no slough or eschar)
    5. Stage 3: Full thickness skin loss with subcutaneous damage (crater to fascia)
    6. Stage 4: Full thickness skin loss with extensive deep damage to Muscle, bone, tendon
  6. Additional findings
    1. Sinus tracts, skin undermining or tunneling
    2. Exudate or sloughing
    3. Necrotic tissue
    4. Granulation tissue
    5. Wound discharge
    6. Wound odor
    7. Signs of Wound Infection or Cellulitis
    8. Skin base quality and surrounding skin integrity
    9. Wound bed color

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